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1.1 “Decision making by nurses is now firmly established in practice, policy and educational agendas. New constantly evolving, roles, and a policy context that is challenging traditional professional boundaries mean that, more than ever, nurses are being given autonomy and power to be able to exercise their decision choices (Thompson, 2001)”.
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1.2 Clinical decision making may be defined as having a variety of options and choices and a process that nurses undertake during their everyday activities whilst caring for service users. It usually involves nurses making judgements about the care that they provide to service users (Thompson et al, 2002). Similarly O’Neill et al (2005) argues that clinical decision making is a complex activity that requires nurses and other health professionals to be knowledgeable in relevant aspects of nursing, to have access to reliable sources of information and to work in a supportive environment.
1.3 Shared decision-making on the other hand is an interactive collaborative process that occurs between the nurse and the service user that is used to make health care decisions. Adams and Drake (2006) note that in shared decision-making “the nurse becomes a consultant to the service user, helping to provide information, to discuss options, to clarify values and preferences and to support the service user’s autonomy” (p.88).
1.4 Policy changes and trends in professional development within the last decade have reiterated the importance that nurses and other relevant health professionals need to recognise that the decisions they make have a direct impact on health care outcomes and service users experiences (DH, 2000).
1.5 Decisions can be easily examined in the form of decision trees which provide a highly effective structure within which many different options can be explored (Goetz, 2010). Goetz (2010) further argues that the decision tree encourages people to think through their options, to act consciously and with consideration. It has also been suggested by Corcoran (1986, cited in Bonner, 2001, p.350) that the decision tree is able to provide a clear structure which helps to assess a range of actions that health professionals may choose when making decisions regarding the care and treatment of a service user.
1.6 In contrast, Bonner (2001) argues that the decision tree is under researched within the scope of mental health practice. He does acknowledge that the use of the decision tree in practice allows nurses to examine the options available to them in more detail, whilst also considering the complex variables that influence the decision-making process.
1.7 It would be expected that the decision tree is hierarchically structured and spans a specific period of time which will be determined within the ‘Justifications’ section of this report.
2.1 The purpose of this report is to identify a service user with whom one was currently working with in practice. Using a decision tree, the service user’s journey will be detailed from their current health needs from the point of referral to mental health services to the current point in time. Once the decision tree is formed, it will then be essential to identify up to three critical decision points and analyse the decision making process for each decision chosen.
2.2 The information required to form the decision tree is to be gathered during a 60-minute unstructured interview with the service user, which can be thought of as a ‘guided conversation’. The reason that this type of methodology will be utilised is because unstructured interviews allow a particular focus on specific areas through asking open-ended questions but also allow for probes and follow-up questions to be used in order to effectively obtain more information to construct the decision tree as accurately as possible (Streubert & Carpenter, 1999).
2.3 In order to ensure that the information gathered is accurate, it will be beneficial to form a ‘lifeline’ with the service user, looking at major life events and decisions that have been made. This lifeline can be found in Appendix 1.
2.4 It will also be essential to explore the service user’s medical notes (with their consent) in order to gain a clearer idea of events that have occurred, the vital decision points and whether service user involvement was evident throughout.
2.5 The decision tree that was formed can be found in Appendix 2.
3.1 The service user that will provide the focus of this report will be referred to as ‘Sarah’ (a false name in order to maintain confidentiality).
3.2 Sarah is a 43-year old lady who has a diagnosis of borderline personality disorder. She has had multiple admissions to psychiatric units including admissions under the Mental Health Act (See Appendix 3 for supporting information).
3.3 Sarah was chosen because it was felt that the she would be able to provide a good history and account of events that have occurred in her past in relation to the care and treatment that she has received. Sarah was also deemed to have capacity and was therefore suitable to take part within this piece of work.
3.4 The timescale that the decision tree covers will focus upon a 6-year history whereby Sarah began her first contact with adult acute mental health services. This will be explored up to the current point in time.
3.5 During the gathering of information, both primary and secondary sources were used. Primary sources refer to first-hand accounts of events that have occurred (i.e. interview with service user). In comparison, secondary sources refer to information that has already been documented from the past (i.e. medical/nursing notes). It was decided to use both sources as they would provide information richer in validity and ensure the reliability of the findings.
3.6 The report will cross the boundaries between in-patient care and community services within the North of England. The key decision points that have been chosen for analysis within this report were chosen because it was evident that some decisions had a certain degree of service user involvement in comparison with others whereby service user involvement did not seem to be present. This does however introduce a debate in regards to service user involvement because those decisions that did not involve Sarah and that were made on her behalf, can be argued were made in the ‘best interests’ of the individual i.e. admission to hospital to ensure Sarah’s safety and well-being.
3.7 Each of the decisions will now be individually analysed with a specific focus upon the decision itself, the issues that they may involve and the concepts that they may introduce.
4. Referred and taken onto caseload with a Community Mental Health Team following gate-keeping assessment (See Appendix 4)
4.1 Sarah was referred to her local community mental health team following a visit to her General Practitioner (GP) whom was worried about the self-harming thoughts that Sarah was currently experiencing. The General Practitioner was very concerned about Sarah’s apparent deterioration in her mental health, therefore he felt that it was necessary to refer her to the community mental health team who would then be able to offer assessment and work from that point onwards. The GP discussed this with Sarah who did admit to being a little apprehensive beforehand however after a short period whereby she was able to reflect on her current circumstances, Sarah was agreeable to this.
4.2 Borg et al (2009) argues that service user involvement has a crucial significance especially for individuals that work within a community mental health setting as this involves accessing patients in their own homes (p.285). Sarah did feel that she had developed a good rapport with her community psychiatric nurse because Sarah was always offered choices in terms of her care and treatment and she felt actively involved in the decisions that were made. The therapeutic relationship that was developed between Sarah and her community psychiatric nurse also played a vital role in Sarah’s care as Reynolds and Scott (2000) argue that it is through this therapeutic relationship that we can assess the needs of the patients that we work with and then plan future care to assist in their recovery.
4.3 An important consideration is the potential risk involved in maintaining Sarah’s mental health in the community. This was clearly documented within Sarah’s treatment plan with specific actions outlined and crisis contact numbers provided to both Sarah and her Husband. The National Institute for Health and Clinical Excellence (2009) provides guidance on risk assessment in patients with a diagnosis of emotionally unstable personality disorder. It informs that the risk assessment should take place as part of a full assessment of the patient’s needs and this is exactly what occurred due to the high level of risk involved and potential self-harm of Sarah within the community.
4.4 The main influences behind the decision to make a referral to the local community mental health team was Sarah’s safety and how able she was to maintain this. Also if the GP felt that Sarah required a hospital admission and there were no hospital beds available, then a referral to the community mental health team or crisis resolution would be necessary. This therefore would indicate that care and treatment is dependent upon what resources are available at that specific time.
4.5 In order to ensure that the correct decisions are made, the specific team must have an effective leadership style and a variety of skills amongst team members. The New Ways of Working practice implementation guide (DH, 2007) outlines how a team can effectively achieve their maximum potential. In order for this to be achieved, a number of measures must be addressed which include;
Focusing upon skills and matching these to the needs of service users;
Distributing responsibility fairly amongst the team rather than delegating;
Focusing on ability and competence of team members rather than role.
4.6 The policy discussed in section 4.5 appears to be utilised well within this team because Sarah was allocated to a senior care coordinator that had a large amount of experience of working with individuals with a diagnosis of personality disorder. The health professional was also able to engage and was competent in carrying out Dialectical Behavioural Therapy with Sarah which is a specialised treatment suitable for those with a diagnosis of personality disorder (Comtois et al, 2007).
4.7 There are many alternate decisions that the General Practitioner could have made in order to ensure that Sarah received the treatment that she required to meet her needs. A referral to the local crisis resolution home treatment team could have been made who would offer assessment and then decide a plan of action. Brimblecombe (2001) argues that a team such as this could have the potential to reduce the number of hospital admissions, therefore utilising resources and funding more effectively but at a cheaper cost.
4.8 Another possible course of action could have been to make a referral to the acute community day services (day hospital) who would be able to provide care throughout the day for Sarah if she required support. This would be a less restrictive alternative than hospital admission and Sarah may be more likely to engage with this service based in the community.
4.9 Alternatively, the GP could have chose to not do anything except review Sarah after a few weeks to assess whether her mental health was still deteriorating however this may be seen as unethical especially if Sarah was suffering due to her experiences and self harming thoughts, which ideally should be resolved as soon as possible.
5. Voluntary (informal) admission to acute psychiatric hospital following presentation in Emergency Department (See Appendix 5)
5.1 When Sarah becomes acutely unwell, the most common course of action is to admit her to hospital for her own safety and well-being but also the safety of others. This particular hospital admission was informal which therefore indicates that Sarah was willing and agreed to go into hospital, having been assessed by a team which specialises in self-harming behaviour.
5.2 The Mental Health Act (2007) refers to informal patients as those that accept and agree to go to hospital without the use of compulsory powers. Sarah was not detained therefore she was permitted to have leave from the ward to spend at home with family. This was Sarah’s choice and was discussed in collaboration with the Consultant Psychiatrist until an agreement was made.
5.3 The decisions to admit Sarah to hospital was made by a health professional that assessed Sarah in the Emergency Department following an incident of self-harm. Sarah did feel that she was fully involved within the decision because alternatives to hospital admission were discussed with Sarah however she felt that hospital admission was the most appropriate action to ensure her safety at that specific time. Furthermore the Nursing and Midwifery Council code states that ‘as a professional, nurses are personally accountable for actions and omissions in their practice and must always be able to justify their decisions (NMC, 2008).
5.4 The main influences behind this decision were the levels of risk involved due to an escalation in Sarah’s self harming behaviours within the community. The Ten Essential Shared Capabilities (DH, 2004) aimed to set out the shared capabilities that all staff working in mental health services should achieve. Promoting safety and positive risk taking is one of the major points within the document with the hope of empowering individuals to determine the level of risk that they are prepared to take with their health and safety. Ideally this includes working with the tension between promoting the individual’s safety and positive risk taking which should be detailed within the individuals care plan.
5.5 Positive risk taking and risk management has been largely debated within the scope of mental health nursing. Parsons (2008) argues that people learn through a process known as trial and error. This therefore suggests that if Sarah self-harmed so significantly that her life was endangered then she would not carry out this behaviour again. This theory however can be largely critiqued in regards to Sarah’s case because the self-harming behaviour is a regular occurrence with Sarah in full knowledge of the consequences that this may have.
5.6 A study carried out by Bowers et al (2005) examined the purpose of acute psychiatric hospital wards and they concluded that in most circumstances, patients are admitted because the possibility of harming themselves or others had increased significantly. They also found that when an individual is experiencing a severe mental illness whereby their behaviour is unmanageable in the community, this provides the requirements for a hospital admission.
5.7 In contrast, the quality of care on acute psychiatric hospital wards has largely been questioned in regards to the usefulness that hospital admission can actually have upon a person (Quirk & Lelliott, 2004). In some circumstances, many individuals will receive high-quality care whilst in hospital however recent studies have suggested that for some individuals, the experience of hospital admission was rather negative (Baker, 2000; Glasby & Lester 2005).
5.8 The Royal College of Nursing (2008) acknowledges that every nursing decision made has an ethical dimension and furthermore that ethics and ethical decision making abilities are applicable to every aspect of nursing practice. The decision to admit Sarah to an acute psychiatric hospital ward does introduce ethical dilemmas because it can be argued that it is unethical to admit a person to a locked ward and therefore restricting their freedom.
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5.9 Beauchamp and Childress (2001) developed a framework which consists of four main principles. The first principle outlines the respect for an individual’s autonomy i.e. respecting the decisions that they make and the reasons for making a particular decision. Sarah was given a choice in regards to hospital admission because she could have been detained under the Mental Health Act (2007) however she agreed to hospital admission and was therefore admitted as an informal patient.
5.10 The second principle is that of Beneficence which examines the benefits of having a particular treatment against the risks involved. This was discussed with Sarah and the reasons for hospital admission were fully explained which were to ensure Sarah’s safety. Sarah understood the health professionals concerns and worries and did accept hospital admission therefore the health professional was acting upon beneficence.
5.11 The third principle is Non-Maleficence which refers to the avoidance of causing harm to an individual. It can be argued that any treatment can have to potential to cause harm however the benefits of the treatment must exceed this which in this case, the benefit plays much more of a vital role.
5.12 The final principle within the framework is Justice which examines the distribution of benefits, risks and costs equally. It therefore indicates that individuals should be treated fairly in similar circumstances and offered the same intervention/ treatment. In terms of hospital admission, the choice would be to go in as an informal patient or be detained under the Mental Health Act using compulsory powers. This decision would be given to most individuals however when capacity becomes a concern then detention may be required.
5.13 There are many alternate decisions to a psychiatric hospital admission which may have been decided. Sarah may have been referred to an acute community day service (day hospital) which offers assessment and treatment for working age adults that are experiencing acute mental health difficulties. A systematic review of randomised controlled trials of day hospitals within the United Kingdom, concluded that day hospital treatment is generally cheaper, the outcomes are greater and that there was greater satisfaction with treatment compared with in-patient care (Marshall et al, 2001).
5.14 Another alternative decision to hospital admission may be a referral to a crisis resolution home treatment team that would be able to provide 24-hour care.
The Mental Health Policy Implementation Guide (DH, 2001) informs that the crisis resolution team is for adults between the ages of 16-65 with a severe mental illness or experiencing an acute crisis that without the involvement of a crisis resolution home treatment team, hospital admission would be necessary to ensure the safety of the individual. This however had been attempted in the past and Sarah did not feel that she benefitted greatly from the service because although they provide a 24-hour service, they cannot offer the same kind of interventions that a hospital ward could offer.
6. Diagnosed with Emotionally Unstable Personality Disorder
(See Appendix 6)
6.1 Sarah was diagnosed with Emotionally Unstable Personality Disorder whilst an in-patient on an acute psychiatric ward. The decision to change Sarah’s primary diagnosis of deep depression with psychotic episodes was made by the Consultant Psychiatrist that was involved in Sarah’s care and treatment.
6.2 The National Institute of Mental Health (2001) describes emotionally unstable personality disorder as a serious mental health illness that is characterised by a pervasive instability in moods, interpersonal relationships, self-image and behaviour.
“The symptoms of emotionally unstable personality disorder are maladaptive behaviour learnt to make sense of the world and to manage the constant negative messages experienced (Eastwick & Grant, 2005)”. It is important to note that Sarah did experience sexual and psychological abuse from an outsider of the family during her childhood which she did not disclose to her family until she was an adult. Sarah recognised that this was a major factor in the way that she perceived the world and was directly linked to her self-harming tendencies.
6.3 During this period of time, Sarah’s behaviour became increasingly unsafe to manage in the community therefore warranting a hospital admission. Her self-harming tendencies had increased and there was a great concern for her safety mainly expressed by her family who were worried about Sarah’s deterioration in her mental health.
6.4 When Sarah was given the diagnosis, she was unhappy due to the non-apparent involvement within the decision as she was not consulted in regards to the diagnosis or asked about her thoughts and feelings. Bray (2003) argues that decision making and service user involvement cannot always occur with individuals that have a diagnosis of emotionally unstable personality disorder due to the varying symptoms that they may experience i.e. impulsive behaviour which can diminish responsibility.
6.5 Once the diagnosis was made, Sarah felt that people’s opinions and attitudes had changed towards her including ward staff. According to Nehls (1999) individuals with a diagnosis of emotionally unstable personality disorder have described health professionals as being unhelpful, displaying negativity and generally being unhelpful.
6.6 A consultation document known as New Horizons (DH, 2009) outlines a cross Government vision in the hope of eradicating the stigma that surrounds mental health and improving the quality and accessibility of services, ensuring that services are service user friendly. The document stresses the importance of mental health and encourages individuals to understand that mental health problems should be equally as important as physical health conditions.
6.7 Services that are provided by the National Health Service (NHS) are commonly built upon effective partnerships between those providing care and those accessing care. The Department of Health (2004) informs that better healthcare outcomes are achieved when the partnership between health professional and service user is at its strongest. Within this particular decision, there was no partnership as Sarah was not involved in the decision making process in regards to her care and treatment and decision to make a diagnosis without consultation with Sarah.
6.8 An important consideration is that of power because the Consultant Psychiatrist that made the decision, created a position of power over the service user through expertise and knowledge. Pyne (1994) argues that knowledge is a form of power, therefore if we share this knowledge with the patients that we work alongside, then this can promote the process of empowerment in patients. The author then progresses to a stage whereby he questions why nurses do not always demonstrate this behaviour in practice. In comparison, McQueen (2000, cited in Henderson, 2002, p. 502) argues that “power associated with special knowledge, that created a barrier between health professionals and patients is slowly diminishing”. Furthermore, McQueen believes that both nurses and patients need to be seen as respected autonomous individuals with something to contribute towards an agreed goal.
6.9 There are alternate decisions that could have been undertaken rather than making a diagnosis of emotionally unstable personality disorder. The Consultant Psychiatrist may have decided to not make a formal diagnosis however this could therefore have an effect on Sarah’s care and treatment as she would not receive the correct care and treatment to meet her needs. Sarah’s previous diagnosis of deep depression with psychotic episodes may have remained the same however it cannot be determined how long this would have lasted due to the frequency of self-harming behaviours and multiple hospitals admissions due to an increased concern for Sarah’s safety.
7.1 It has become evident that the three chosen decisions for analysis had common themes running through each decision. Power has become an important consideration because although Sarah had a degree of power within each decision, the overall decision was made by those within higher positions i.e. hospital managers and leaders. This can therefore provide the service user with a false misinterpretation of the power that they actually withhold as it is clear that the final decision is not made by the service user and instead it is those with more power i.e. the GP making the referral to the community mental health team and the Consultant Psychiatrist changing Sarah’s diagnosis to emotionally unstable personality disorder without consulting Sarah beforehand.
7.2 Leadership has been defined many ways in the literature reviewed, however several features are common to most definitions of leadership and the forms that it can take. Faugier & Woolnough (2002) argue that leadership is a process which usually involves a certain degree of influence, but also with a focus upon the attainment of goals .The leadership style mostly present within each of the key decisions is that of a democratic style because there was a degree of consultation with staff on proposed actions before an actual decision was made.
7.3 The care and treatment provided to Sarah was driven by ‘resource availability’ and this was clearly evident within each decision. If resources are not available, this would impact on the decision whether to allow Sarah to have the treatment. The admission to an acute psychiatric hospital for example would be dependent upon the capacity of that specific organisation because if there was not a bed available for Sarah then other alternatives would have been considered. Fortunately there were resources available for Sarah, however the outcomes may have been different if this was not the case.
7.4 Sarah had also had a large amount of input from a number of services and there was a large amount of movement through mental health services. It can be argued that this is not beneficial towards service users as they are not able to sustain good therapeutic relationships with health professionals which can often be a reason as to why an individual may relapse.
8.1 Decision-making within practice takes place in many ways i.e. often the service user is consulted throughout their care and treatment however in some circumstances the service user can be made a recipient of their care and treatment which is not good practice. This report has identified a patient that one is currently working with and using a decision tree, their journey through mental health service was detailed. Three decisions were chosen for analysis and provided the basis of this report, considering factors that influence the decision-making process and also the alternatives that could have occurred.
8.2 Barker et al (2000) argues that the experience of being mentally unwell can be a disempowering period of time because choices can be taken away due to a number of reasons and the patient may feel a recipient of their care and treatment, rather than actively involved in the decision making process.
8.3 “Defining decisions as good or bad is problematic, mainly because nurses operate in an environment that is characterised by uncertainty (Buckingham et al, 2000)”. Baron (2000) further suggests that the best decisions are those that produce the best outcomes for achieving a patient’s goals and wishes.
8.4 Sarah did feel the majority of time that she was involved in her care and treatment, including reviews and meetings held about her care and treatment whilst an in-patient and within the community. There were times however when Sarah did not feel involved in the decision making process i.e. when her diagnosis was changed without any consultation or discussion.
8.5 Clancy (2003) argues that there is a great tendency in decision-making to bypass a thorough analysis and jump too quickly into solutions. This seems to be evident at times within the chosen decisions for analysis because some decisions were made on behalf of Sarah and there was no consultation or service user involvement.
8.6 Throughout this report, the main aim was to analyse the decision-making process of three key decisions, taking into consideration concepts such as; autonomy, power, leadership and empowerment. It became apparent that they key to successful decision-making was to involve the service user and carers within the decision-making process, listening to their thoughts and opinions and respecting their right to choose between different alternatives.
8.7 It has also become apparent that those within higher positions and those that uphold a certain degree of power were leading the decision-making in Sarah’s care. This is obviously not the way that things should work as the service user should be actively involved in all aspects of their care and treatment including decisions that are made.
8.8 Overall I feel that the whole process was an enjoyable one and I feel that I worked well in collaboration with the service user throughout. Collating the decision tree was a rather time-consuming activity, however I understand the importance that they hold and the benefits they possess. I have also become more aware and gained a greater understanding of how the decision-making process can impact on the lives of service user and carers, especially when service user involvement is not evident.
There should be a greater focus upon the decision-making process and how it can affect the service user.
Decisions should be decided in collaboration with the service user to promote the nurse-patient relationship and allow good rapports to establish.
Service user and carer’s should be actively involved in the decision making process.
Decision making should be an identified topic for pre-registration nursing students to equip them with the desired skills.
Decisions are to be based on the best available evidence and regularly discussed with users and carers ensuring that an understanding has been reached.
Service user’s thoughts, feelings and opinions to be clearly documented to inform future nursing practice in regards to decision-making.
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