Qualified nurse during a clinical placement Essay

Decision doing try

Decision devising is of import to nurses in today’s society. ( Thompson et al 2002 ) as a figure of policy and professional jussive moods mean that nurses have to worry about the determinations they make and the manner in which they make them. The authorities has produced several policy enterprises ( DOH 1989. 1993a. 1993b 1913c. 1994. 1995. 1996a. 1996b. 1997. 2000. 2000 ) which have led to the creative activity of an grounds based wellness attention civilization ( Mulhall & A ; Le May 1999 ) . Thompson et Al ( 2002 ) believe that hapless determination devising will no longer be acceptable.

the authorities purpose to analyze professional public presentations and the result of clinical determination devising for the first clip. Evidence based pattern will no longer be an optional supernumerary but a demand of all wellness attention professionals.

The purpose of this essay is to analyze and measure a determination made by a nurse in a community pattern. The writer will foreground why she chooses the peculiar issue and how it is of import to nursing.

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The writer will supply an overview of two general attacks to determination devising. rational and phenomenological. by measuring and analysing them. The writer will see determination devising theories. and seek to use them to the determination doing procedure witnessed in her community arrangement. She so aims to demo. how they should or could hold been used as an assistance in effectual determination devising. She will besides see act uponing factors that effected the determination devising procedure. A anonym is used throughout the essay to protect the patient’s individuality.

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as stated in NMC ( 2002 ) codification of professional behavior subdivision 5.

The patient chosen for the intent of this essay will be referred to as Jo. Jo is 53 twelvemonth old adult females who suffer with arthritic arthritis. This besides resulted in Jo holding bilateral hip replacings. Jo is on steroid intervention. which leads to cutting of the tegument and susceptibleness to trauma ( Mallet and Dougherty 2001 ) . Jo lives with her hubby and two grown up boies. Jo was refereed to the territory nurse on her discharge from infirmary following her 2nd hip replacing. The initial referral was to look into the surgical lesion. However on reaching it was pointed out by Jo that she had a skin tear on her left shin that wasn’t mending. The territory nurse performed an appraisal and concluded the lesion was a venous leg ulcer as it had been present for 6 hebdomads. The territory nurses used Sorbisan and Telfa to dress the lesion. Twice hebdomadal visits were carried out to Joe for a farther 4 hebdomads. and it became obvious that the ulcer was non bettering. The territory nurse had to do a determination on what attention to supply. The determination was to seek another dressing Aticoat which is impregnated with Ag. and non to mention the patient to the leg ulcer clinic at the local infirmary. The territory nurse involved with Jo’s attention was a G class nurse and in charge of a community pattern that had 3 other nurses working in it.

The writer decided to concentrate on this peculiar determination. as she was influenced by the sum of grounds based research available on the issue. and how the territory nurse chose to disregard the grounds. and made a determination on the footing of personal cognition. The writer visited a leg ulcer clinic while on her community arrangement. and asked the adept nurses running the clinical at what phase they would wish to see patients referred to them. She was told if a lesion wasn’t healing after 4 hebdomads the patient should be referred. this information was passed on to the territory nurse and ignored.

The territory nurses felt that if he referred all his patients after 4 hebdomads the leg ulcer clinic at the infirmary wouldn’t be able to get by. In making this he chooses to disregard the adept advice. I found this really frustrating and interesting. and as Scott ( 2004 ) said we ought to advance good and non do injury. in Jo’s instance. the action of non mentioning her to the appropriate expert nurse could be seen as protracting mending therefore doing her injury. I decided to look into farther what issues led to him doing his determination.

To accomplish excellence in attention nurses need to establish there determination on grounds based attention ( Parahoo 2002 ) . There is no deficit of research on lesion attention and the direction of venous leg ulcers. However because research is based largely on sentiments or experience. hence the development of guidelines and protocols that have practical usage is hard ( Leaper et al 2004 ) . There are many beginnings of grounds. Journal ; the Cochran Library database relevant to injure attention. nevertheless there is so much information it would be hard for nurses to cognize where to get down. Evidence suggest the direction of patients with venous leg ulcers is fragmented and ill managed ( Carrington 1999 ) .

Vowden ( 1997 ) agrees and suggests mending rates are hapless and intervention costs are high. this could be as a consequence of nurses non mentioning patients to allow experts for appraisal and utilizing expensive. inappropriate dressings such as aticoat. which is impregnated with Ag. Although there is grounds to propose that dressing impregnated in Ag and sorbisan are extremely effectual in to a great extent exuding lesion ( Leaper et al 2003 & A ; BNF ( 2004 ) Jo’s ulcer was shallow and non to a great extent exuding. The grounds for the attention of venous leg ulcers strongly points to the utilizations of 4 bed dressing. This is demonstrated in Allen and Nelson ( 1996 ) work. they found that mending rates improved for patients who attended a leg ulcer clinic and had 4 bed dressing applied.

This is besides backed up by grounds 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 compaction dressing. Jo had suffered with her leg ulcer for 10 hebdomads before a determination was made by the District nurse to alter the dressing from Sorbisan to Aticaoat. The usage grounds based attention. provides the foundation for grounds based pattern ( Harding et al 2002 ) . the ulcer healing rate and result for Jo could hold been improved by a speedy referral to the leg ulcer clinic. as this is seen as the most effectual manner to handle leg ulcers ( Musgrove and Woodham 1995 ) .

One of the grounds the territory nurse was hesitating about mentioning Jo to the ulcer clinic. was that he felt compaction banging is uncomfortable and requires a rigorous government ( House 1996 ) . and his experience patients didn’t frequently comply. However Jo was non offered the pick. Taylor ( 1996 ) believes
that communicating with patients is important to conformity. he suggest by educating patients it will enable them to understand the importance of the compaction and assist patient to follow to intervention. Patients need to be given the option of whether they are involved in the determination devising procedure. In Jo’s instance the territory nurse made the determinations. he didn’t explain alternate interventions to Jo. or explicate the 4 bed dressing to her. In the writers sentiment the patient was non given an informed pick.

There is a professional duty to obtain informed consent from patients before a nursing attention process is carried out ( Cable 2003. Averyard 2000. NMC 2002 ) . The ethical issue of informed consent came basically from the Nuremberg Code ( 1947 ) as a consequence of human experimentation in universe war two. This was aimed specifically at worlds involved in medical research. nevertheless consent is now applied to nursing clinical processs ( General Medical Council 1988 ) . There is increasing grounds to propose that intelligent patients manage their wellness and intervention better. this enables them to experience in control of there unwellness ( Ogden 2001 ) and have better psychological results ( Gibson 2001 ) .

Although Gibson ( 2001 ) argues that cognition entirely does non alter wellness results for patients. to let Jo to give informed consent she would necessitate information that was relevant to her status and intervention. Jo is an intelligent adult females and giving her a pick of intervention would hold protected her liberty ( Edwards 1996 ) and single rights ( Caress 2003 ) . nevertheless Jo was non offered a pick in intervention. and options were non discussed. The territory nurse made a determination and applied the intervention.

In making this the territory nurse used his power to pull strings Jo into accepting the intervention the he wanted to give. Giving restricted information the nurse restricted the patient’s picks to procure her conformity ( Lukes 1974 ) . The territory nurses actions went against recommending the authorities Expert Patient Policy ( DOH 2000 ) . which highlights the demand for alterations in society that average persons expect to hold picks. and be involved in determination devising ( Kenney 2003 ) . Although Jo gave consent for the intervention given. she did non. in the author’s sentiment. give informed consent.

Decision devising can be divided into two groups. determination doing from a positivist position and from a phenomenological position ( Tanner 1987 ) . Rational determination devising is a measure by measure attack that follows a logical class. and clearly definable phases ( Harbison 1991 ) . taking into history obvious get downing points and aims. appraisal tools. policies and protocols. It gives clear predictable results and is process driven. Rational determination devising plants. on the footing that when a job arises. the determination shaper agrees a definition of the job and discovers all the possible solutions. matches the job with the resorts and chooses a solution that best matches the job. and so implement solution ( Harbison 1991 ) . This attack fits in good with the current tendency towards research and grounds based attention ( Harbison 1991 ) . Using the rational attack to determination devising. makes premises that all determination shapers will take into consideration all possible options and effects. in visible radiation of a thorough apprehension of a state of affairs. However in pattern this attack would be influenced by clip restraints. wont and modus operandi. and Harbison ( 1991 ) argues that sensitiveness could be lost when following a rational attack.

Using Phenomenological procedure in determination devising can be seen as a subjective single attack ( Easen et al 1996 ) . This attack takes into history nurses sentiments and positions. for this ground as discussed by Thompson ( 1999 ) it can make prejudice. as it is based on experient expert cognition. Using adept clinical concluding the nurses draws on a deep apprehension of the patient state of affairs and holistic attention demands. Intuition is a quality that nurses have traditionally valued ( Trueman 2003 ) . nevertheless with the development of grounds based attention it is now seen be some to be undependable. unscientific and unsuitable for nursing pattern ( Trueman 2003 ) . Intuition has been criticised for non being able to supply a rational for the determination made. nevertheless Benner ( 1984 ) believes intuition is understands without a rational.

Benner ( 1984 ) argues that during a long nursing calling. nurses can derive a great trade of cognition and accomplishment pattern. this leads to them being intuitive about the determinations they make. Intuition is non something that is mensurable harmonizing to Benner ( 1984 ) . it is developed through experience. expertness and cognition. along with personal consciousness and personality. McCutcheon and Pincombe ( 2001 ) besides believe that there are benefits derived from intuition in pattern. such as enhanced clinical judgement and effectual determination devising. Although Cioffi ( 1997 ) argues that holistic patient appraisal and bettering nurse-patient relationships are being undermined by a thrust for grounds based attention. Intuition has been identified as a utile tool as nurses can analysis the state of affairs as a whole instead that a series of undertakings ( McCutcheon and Pinchcombe 2001 ) .

Both the phenomenological and rational determination doing theories have a figure of strengths and restrictions. McKenna ( 1997 ) argues that cognition can merely go known by others if it is shared cognition and communicated to others. McKenna ( 1997 ) suggests this causes a job for the phenomenological theoretical account it is about impossible to pass on something which is intangible. and which the practician is unable to show. Using a mixture of both theories can make a holistic and good documented process.

Lauri and Saklantera ( 1995 ) utilizing a factor analytical attack found grounds that both Benners ( 1984 ) intuitive theoretical account. and the hypothico- deductive attack of information processing. had a grade of analytical utility in explains the determination devising of nurses. The deductions were that both had something to offer and neither is frequently a individual solution to explicate determination devising in pattern.

Using a determination doing theoretical accounts such as Carroll and Johnston ( 1990 ) would hold enabled the territory nurse to reflect and measure the effectivity of the attention delivered. Carroll and Johnston ( 1990 ) sketch seven phases of temporal determination devising. and acknowledged that these phases may non merely be followed through there sequence. but the nurse can turn back at any phase. The first two phases of acknowledgment and preparation involves the scrutiny and categorization of the state of affairs by the territory nurse. During a place visit the community nurse may be confronted with a scope of patient jobs ( Bryans and McIntosh 1996 ) . Some of these are distinct and easy recognised. while others are likely to dependent upon assorted fortunes in the patients life. which are likely to stay concealed unless they are explored by the nurse ( Bryans and McIntosh 1996 ) .

In position of the fact that patient and nurses are aliens to each other. Thompson et Al ( 2002 ) believe this geographic expedition must be skilfully negotiated by the community nurses. if nurses suitably identify demands. and therefore get down the procedure of turn toing these demands and planning suited attention. If this portion of the appraisal had been undertaken efficaciously by the territory nurse. the patient may non hold suffered for a long period with the leg ulcer. Bryans and McIntosh ( 1996 ) suggest this stage of determination devising is by and large less witting and deliberate. and more hard to joint. than subsequent stages. Although Elstein et Al ( 1978 ) suggest this a really of import portion of determination doing it frequently gets neglected.

Many determination doing theoretical accounts start with an assessment stage such as Walsh ( 1998 ) nursing procedure. which has four phases of determination devising. appraisal. planning.

execution and rating. If the appraisal carried out by the District nurse is hapless so the remainder of the planning and attention delivered will be hapless. It has been highlighted in many publications Lait & A ; Smith ( 1998 ) . Lawrence ( 1998 ) . Thompson ( 1999 ) that a holistic appraisal is needed in the attention of patients with leg ulcers. Holistic appraisals help to place implicit in pathology. and guarantee right diagnosing ( Moffat & A ; O’Hara 1995 ) . However the manner each single nurse views the lesion will depend on there experience and whether they have come across a similar state of affairs before ( Thompson et al 2002 ) . Walsh ( 1998 ) highlights the demand for a end to mensurate against in the assessment stage. In Jo’s instance the tool used. could hold been a wound chart.

A wound chart was nevertheless was non used. so on subsequent visits the nurse’s used at that place ain judgement on whether the lesion had changed. It was nevertheless hard to clearly sort the lesion. a point highlighted by Flanagan ( 1997 ) who warns wound categorization can take to incompatibilities in attention. Different nurses visited each clip doing it hard to supply continuity of attention. The territory nurse had defined the aim. which was to handle the leg ulcer. However the planning stage of Walsh ( 1998 ) theoretical account was non implemented. the nurse did non see an option every bit identified as of import in Schaefer ( 1974 ) theory. The best result. in the territory nurses position. was considered although non in an grounds based manner.

Carroll and Johnson ( 1990 ) refer to the common sense position of determination devising. in phases 3. 4. and 5. alternate coevals. information hunt and judgement or pick. These three phases can be associated with job work outing attacks and with conjectural deductive theoretical accounts such as Dowie & A ; Elstien ( 1988 ) . Conjectural deductive method could hold been used to place what was traveling on with the lesion e. g. blood trial could hold been taken to prove for coagulating factors. a Doppler could hold been used to prove for circulation. However nurses can’t ever wait for a lab trial to give a hypothesis so the territory nurse so

Drew on his experience. However utilizing contemplation in action ( Schon 1983 ) and taking into consideration of the added job of Jo being on steroids. he could hold put these things into action to assist make an grounds based attention program. Carroll and Johnston ( 1990 ) usefully includes determination devising and subsequent ( stages 6. 7 ) action and feedback. The inclusion of action and feedback in theoretical accounts of determination devising has particle relevancy to Jo’s community nursing appraisal. because her appraisal was uninterrupted in nature ( Cowley et al ( 1994 ) . If the territory nurses had utilized the information decently the result for Jo may hold been more successful. The best result for the patient depends on the patient’s response to intervention the nurse’s intercession and appropriate usage of information gained from the rating ( Luker and Kenrick 1992 ) .

District nurses need to be flexible in supplying attention in patients ain places. because of the sheer diverseness of place environments and life styles of there patients. Luker & A ; Kenrick ( 1992 ) believe that community nurses have at that place own personally owned cognition that they find hard to depict. Benner ( 1984 ) would depict this as intuition. However many act uponing factors are involved with the nurses determination devising. the territory nurse that treated Jo had 20 old ages experience. but in the writers sentiment had non used reflective and grounds based pattern. The usage of contemplation enables nurses to larn from at that place experience and construct up an expert cognition base. However if you don’t larn from your errors it doesn’t do you an expert.

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Experience doesn’t ever equal expertness. If you are a uneffective nurse to get down with you may ever be a uneffective nurse. The territory nurse involved with Jo’s instance didn’t seem to reflect upon his actions and learn from pattern but merely performed a undertaking. Equally long as the patient was being visited twice a hebdomad it didn’t seem to count how long the lesion took to mend. as Thompson et Al ( 2002 ) suggest 20 old ages experience may be no more than one old ages experience repeated 20 times.

Harmonizing to Walsh and Ford ( 1990 ) there is a demand for assertiveness and this was unhappily missing. Walsh & A ; Ford ( 1990 ) argues the deficiency in assertiveness may be generated from being a chiefly female profession. and Corbetta ( 2003 ) suggests adult females that work tend to be judged as inferior. However the territory nurse involved in this determination doing essay was a adult male. so I would oppugn whether societal conditioning had rubbed of on him. The territory nurse seemed to defy changing his pattern as directed by the ulcer clinic. it was about as if he had ownership of the patient’s job and attention. and he saw it as a failure if he had to mention the patient on to a specializer service.

It is the opposition to alter pattern that is cited by several writers ( Gould 1986. O’Conner 1993. Koh 1993 ) as major influence suppressing the debut of research into pattern. However Parahoo ( 2002 ) suggests to alter the manner nurses work. utilizing grounds based pattern. nurses need to believe about what they do. how they relate to the people they care for and by and large excite a more reflecting and oppugning attitude. Reading research articles can bring forth a brooding attack ( Parahoo 2002 ) although the writer is cognizant that altering patterns based on one research article is insecure.

Nurse directors have an of import function in co-ordinated attempts. aimed at supplying effectual grounds based attention. Although non all nurses are inclined towards academic work ( Jootun 2003 ) . the territory nurse was the director so without him being cognizant and appreciative of nursing research his squad of community nurses provided an unequal service. However as Sleep ( 1992 ) states it is unjust and unrealistic for educational programmes to put upon practicians the load of presenting research into the workplace. unless the clime prevailing in both service and direction domains is receptive to alter.

The administration needs to ease alterations in nursing to let the professional as a whole to pattern grounds based attention ( Parahoo 2002 ) . The territory nurse worked in a little stray pattern and his precedence seemed to be the puting up of new PCT policies. Patients with leg ulcers were about in the manner. If the territory nurse had a positive attitude towards research and on a regular basis read research articles on lesion attention. which as Gould ( 2001 ) suggest are available in digestible signifier. the attention provided would hold been grounds based effectual attention.


Joint instruction and clinical calling tracts are needed to shut the theory pattern spread. Many nurses working in little patterns are non acquiring the instruction they need to turn out the authorities with a extremely effectual and trained work force. Many organisations within the NHS are busy and overworked. The clip is non available for them to update their cognition and preparation. To assist nurses who work in stray community patterns the puting up of groups or research meetings could enable them to maintain up to day of the month with relevant research. and would enable the effectual use of research findings. Nurses can besides be encouraged to utilize adept nurses that are available at many infirmaries and PCT. The usage of computing machine webs and synergistic package and research newssheets could besides help in the execution of research pattern.


Carroll & A ; Johnston ( 1990 ) supply a model for determination devising. the writer feels if the territory nurse had used such a model the attention delivered to Jo could hold been more effectual and grounds based. The District Nurse didn’t evaluate or reflect on the attention he delivered. Using determination doing theoretical accounts such as Carroll and Johnston ( 1990 ) and Walsh ( 1998 ) nursing procedure. the nurse could hold delivered grounds based brooding attention. Models such as these are used as a guideline to nursing processs. if they are followed it ensures that patients get best attention and that nurses don’t become complacent in the attention they deliver. but use a systematic attack alongside there experiences and expertness


Intuition has been identified as a utile tool that needs to be recognised within nursing. nevertheless a demand for a ration attack along side it is necessary. This will enable nurses to supply grounds based attention with clear principles. There are many facets of nursing that can non be subjected to measurement. and intuition is one of them. and so is caring. To disregard intuition as a nursing accomplishment would be to deny the patient of genuinely holistic attention. However I would state that the nurse involved with Jo’s attention was non an expert in the attention of leg ulcers. and was establishing his attention on limited research. The consequence this had on the patient was a hapless criterion of attention.

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