Example Of Clinical Decision Making Nursing Essay
Using an example of clinical decision making from you practice experience, utilise evidence to critically analyse the key influences in the decision making process. Critically reflect on how this may impact on your future professional development and practice.
For the purpose of this assignment I will reflect on a clinical decision I made during the assessment of an elderly patient in my care, who I considered to be at risk of pressure damage. I will reflect on the outcomes of the initial assessment and the clinical decisions about the preventative interventions as part of the patients holistic care plan. The rationale to focus my assignment on this topic; is the high prevalence of pressure damage in elderly patients. Chambers (2009) states that over 400,000 individuals in the UK will develop pressure damage with an annual cost of around £1.4- £2.1 billion within the National Health Service (NHS). The Royal college of Nursing (RCN) (2011) suggests that new pressure damage occurs in 4-10% of all patients admitted to hospital in the UK. The National Safety Patient Agency (NSPA) (2010) highlight pressure damage as one of the ten most common patient safety concerns and say it causes unnecessary discomfort and pain to patients further increasing the risk of morbidity. Gorecki (2009) consider pressure damage represents a major burden to patients, including negative psychological, physical, and social consequences affecting health, well-being, and health-related quality of life. Livesley et al (2002) elaberate on this by considering pressure damage has an important consequence both for patients and for the health care system. They can lead to severe or intolerable pain, are prone to infection, and are associated with high mortality rates. Pressure damage is presents a risk to patient safety and its prevalence is one of the harms identified and monitored as part of the NHS safety thermometer (2012) providing a standard method for surveying patient harms and analysing results to measure and monitor local improvement and provide harm free care. However, pressure damage is avoidable and can be prevented (Grewal et al 1999) with regular nursing observations and monitoring to prevent pressure damage from occurring.
The Nursing and Midwifery Council (NMC) (2012) considers that nurses must be able to recognise deteriorating health and respond promptly to improve the health and comfort of the patient. Pressure assessment tools assists the nurse in identifying deterioration of skin and their patients risks of developing pressure damage and support the nurse in making clinical decisions about longer term prevention and management. The assessment process, the identification of risk factors and the treatment choices during the early stages of pressure damage can halt the breakdown of tissue and prevent progression to a more severe grade of damage.
Assessment is the first part of the nursing process and the information generated assists in minimising patient risks and helps to formulate a plan of care. The initial assessment also provides a base line from which to reassess and measure changes in the patient’s condition and inform clinical decision making.
Clinical decision making is a process that allows the nurse to make judgements and build hypothesis based on their past experience and knowledge of a condition, and the information gathered through assessment. As the nurse begins to see emerging cues during the encounter with the patient their hypothesis may change depending on the information collected and the ability to act on their experiences. Thomas (1997) considers that practitioners can become expert decision makers and rapidly develop hypotheses based on their past experience as they have a wide knowledge base and consider the expert has become an expert because they have seen it before. However Banning (2007) considers nurses often use the information procession model of decision making which is based on structured medical decision making processes. The information procession model introduces tools such as decision trees or algorithms to support patient assessment. These tools are often used alongside protocols and guidelines and are used to trigger responses and predict potential outcomes. The Braden scale (1987) is a decision tree which is widely used in healthcare to predict the patient’s risk of pressure damage. The scale uses cues to score patient risks based on pre-determine information.
Using the trigger tool, such as the Braden Scale (1987) the nurse will gather information about the patient, and then develop a hypothesis based on the information. Banning (2007) considers the hypothetic-deductive approach involves cue recognition, generation of hypothesis, interpretation and evaluation. Thompson (2002) believes nurses use a varied range of information when making clinical decisions including verbal communication received from other practitioners, observations, existing knowledge and written information. Hedberg (2003) suggests that nurses using hypothetico – deductive approaches and often collaborate with colleagues to validate clinical decisions, this is considered to be linked to uncertainty about their decision. Manias et al (2004) considers that the lack of experience from practice results in reliance on algorithms to support decision making. Buckingham et al (2000) however warns that the reliance on data within the hypothetico-deductive model has disadvantages in that the decision could have inaccuracies which would therefore invalidate the outcome and results. Banning (2007) reflects the model also relies on nurses ability to recognise cues within the decision tree or situation and match the response accordingly.
Thompson et al (2002) believes the nurse makes intuitive decisions which are based on their prior knowledge and experience. Banning (2007) says this is based on the intuitive – humanist model of clinical decision making which is focused on intuition and the relationship between nurses experience and knowledge. In this model hypothesis testing isn’t used as a marker of the decision outcome. Benner (2001) explores the intuitive decision making process and considers that practitioners develop in practice using a model created by Benner (2001) called from novice to expert. Benner (2001) considers as the nurse gains experience they become less reliant on analysis and using existing knowledge and past experiences. Decision making becomes intuitive and they act on hunches and feelings. Banning (2007) cites Schrader et al (1987) who considers intuition is about knowing something immediately without the use of reason and considers intuition is linked to experience. Green (2012) considers decision making is enhanced by nurse’s previous experiential learning. Davis et al (2002) say that the nurse’s knowledge is based on recognising cues which they refer to as pattern or similarity recognition. Benner et al (1987) believe intuitive judgements are linked to pattern recognition. Banning (2007) says pattern recognition happens when the nurse compares patients signs and symptoms with similar patients from their past in order to match trends. Banning (2007) considers this ability to develop pattern recognition develops as knowledge and experience increase. Cioffi (2000) suggests that a problem with the intuitive model is its effectiveness for inexperienced nurses and considers that for inexperienced nurses to gain skills in clinical decision making they will need a support and guidance from more experienced nurse. Benner (2001) highlights the novice has had no prior experience from situations and they must be guided through patient care. As such the novice will need a high level of advice and support from a mentor and will use procedures and guidelines and analyse all the available data to support their decision making. However, the novice will move to become advanced beginner once they have gained experience from situations and can recognise what Dreyfus (1982) considers aspects of a situation. Benner (2001) considers aspects are cues that the nurse is able to identify from past experience.
During a recent placement a frail elderly patient was admitted to my ward following a fall. I was asked to undertake the patient’s initial assessment. The patient’s history highlighted she had very limited mobility following a fall five years ago in which she dislocated her hip. The patient had partial hearing and her eye sight was poor. Although she walked with a frame, she has had a number of falls in the past year and says she likes to just sit in her chair as she is a bit unsteady. Using reflective frameworks I will review my actions during the patient assessment and the decisions made throughout process. Carper (1978) considers the way in which an individual understands what is to be achieved and how they respond to meet the intended outcomes is known as the aesthetic way of knowing. Based on the initial information I gathered from the patients admission notes and by observing the patient I instinctively knew she was at risk of pressure damage. Reflecting on why I though the patient was at risk I think I just “knew”. Her age, frailty and limited mobility provided indicators for me to undertake a pressure assessment. Rolfe et al (2001) cite Dreyfus et al (1986) who suggests that this intuition is actually based my past experience and knowledge of pressure damage which enabled me to pick up on cues and come to a quick conclusion. Carper (1978) describes this as aesthetic knowledge as it required me to make a choice of what action to take based on my knowledge and skills and interpretation of the patient’s condition. Benner (2001) considers the nurse acts on cues from the presenting patient and sub-consciously compares these to reoccurring situations from past experiences. Reflecting on the patient these cues were based on my knowledge of pressure risk factors and from experiential learning gained with similar patients. Johns (2009) says responding to the situation in terms of what is the best action to take is linked to the ethical way of knowing.
I decided to use the Braden Scale (1987) to assess the patient as this tool is identified in local guidelines as an appropriate method of determining pressure risk. Baranoski et al (2004) considers a first step in the decision making process is reviewing the reliability and validity of the tool. In the Braden scale validity can be measured by predicting whether a patient will or won’t develop pressure damage. Johns (2009) considers that my decision to use this trigger tool is based on empirical knowledge, which is based on providing measurements that are objective; research based and can predict outcomes. The assessment required me to use my own judgements about the patient’s health status and score her appropriately within the scale. The patients Braden score was 15, which was based on a number of factors including her poor mobility, her confinement to her chair for long periods of time during the day and her requirement for assistance to move. There was also a risk of shear caused by friction between her skin and the chair as she moved. The outcome of the Braden score supported my initial gut feeling. Using the Braden results alongside trust guidelines I was able to make a clinical judgement about the preventative interventions required to minimise the patient’s further risk of pressure damage.
Baranoski (2004) says identifying the risk enables the clinician to make decisions about when to start using preventative measures. Carper (1978) suggests interpreting, reflecting, and responding with appropriate action links with aesthetic ways of knowing. Using the clinical guidelines and again drawing on experience I decided to develop a plan to manage the patient’s risk of pressure damage. This included ordering a cushion for her chair to improve her posture and allow her weight to be distributed away from bony areas and reduce the risk of skin shearing. Stockton et al (2012) consider the nurse needs to make a clinical decision at this stage about the type of cushion to use linked to which will be the most appropriate to the individuals need. My decision was based on local guidelines and availability of equipment. Other equipment I identified included an airflow mattress for the patient’s bed, which again was aimed at redistributing pressure on her body; I also concluded that the patient would benefit from frequent positional changes while in bed either resting or sleeping.
However, I didn’t have the confidence to immediately act on my decisions and implement preventative care without seeking advice and reassurance from my mentor. Benner (2001) considers this need for support from the mentor is typical of an advanced beginner. Johns (1995) says this allows the practitioner to share their story by reflecting on actions, and also resolve any contradictions. Jasper (2006) suggests reflection is based on a number of cues including what, where, who, when, why and how. For me this was reviewing the assessments I had undertaken and why I decided to use the Braden Scoring tool, what my findings where and how I had decided to recommend this patient for preventative care. Reflecting with my mentor helped me to confirm my decision as well consider wider options. Rolfe (2001) considers working alongside a mentor offers the advantage of having live supervision, providing training and reflection in action. Jasper (2006) considers reflecting with others can result in us reflecting deeper, as well as validate our thoughts in addition to contribute wider knowledge or suggesting different course of action. Jasper (2006) consider that practitioners need to be able to justify their decision as they become independent practitioners and be prepared to debate and defend their decisions. Jasper (2006) links reflection to the experience, refection and action (ERA) cycle and says the experiences provide the topics for practitioners to reflect on and learn from.
Reflecting on my experiences of clinical decision making, I believe that I have developed confidence in my decisions as I have become more experienced and knowledgeable. I also have the confidence to act on cues, and hunches whether this is about implementing a care intervention, or prompting me to seek advice. The NMC (2012) consider nurses should recognise the limits of their competence and knowledge. They must reflect on these limits and seek advice from, or refer to, other professionals where necessary. Although I still sought advice from my mentor, there were aspects of the assessment process that I had instigated independently. I made clinical decisions about when to assess, what assessment to use and which cues to use to inform the assessment. Once the assessment was complete I then made judgements to support a plan of care for my patient.
I feel that the process of reflection in action assisted my personal development, by allowing me to learn from my experience and use this learning to inform my future practice. Garrett (2005) found that most students believed that clinical experience developed their decision making skills. I believe that the reflection allowed an element of problem based learning. Ness (2010) cite Barrows et al (1980) who consider this allows the student to theorise about what is happening , and what is needed. Kolb et al (1984) suggests there is a link between how we learn and how we practice, it’s about having an experience and then reflecting on it. Reflecting with my mentor required me to undertake critical thinking in order to learn from my experience, thinking about what, why, when, who and how as described by Jasper (2006). The learning generated will inform my future clinical decision making as I make the transition from student to qualified nurse and move from novice to expert as described by Benner (2001). I believe that I sought further validation from my mentor because as I am still a student I cannot be held fully accountable Peate (2006) suggests to be accountable the nurse needs to be in procession of up-to-date knowledge and possess appropriate nursing skills, he further states for this reason student nurses cannot be expected to be held accountable as they may not have acquired appropriate skills or knowledge. I feel that although I was seeking reassurance from my mentor I was confident in offering structured reasoning for my decision making. My intuition that my patient was at risk of pressure damage based on the cues I was seeing was reliant on my past experiences, the use of the Braden scale (1987) provided a source of information which I was able to analyse to support my decision making. Jasper (2006) states that when making a judgement the practitioner must have an awareness of both intuitive and analytical thinking and be able to switch between the two. Although I feel that experiential learning and reflection have supported my ongoing development in decision making I recognise the importance of ongoing training and supervision to support my professional development. This will ensure that I am up to date with evidence based practice as I continue to make the transition from novice to expert.
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