decision making by a nurse

University Degree Subjects allied to Medicine

Student number: 06974264

Analysing a decision made by a nurse in the practice setting

We are going to analyse the decision taken by a nurse to use compression bandages therapy onto a patient who had a venous leg ulcer.

This decision was taken using guidelines and suggested methods, along with their ability to critically question practice in an organise manner, consequently developing the process of decision making (Lipman et al, 1997). Using these and prior knowledge and understanding of the areas we work, an evidence and knowledge based decision can be made, giving the patient options so that they can decide what care they wish to receive. Many studies show that most patients prefer to be involved in decision making, sharing information and decicions with the patient usually means a satisfied patient. It is important to maintain an effective holistic care management and assertive behaviour to create accurate decisions based on all facts and opinions of both parties (Nursing times, 2004). It is essential to have ethical principles in order to provide and maximise the effectiveness of the care provided (Doh, 2006) and ensure that the patient can lead the best possible life that they wish to, for as long as possible.

The patient being cared for is a fifty-three year old man who had various wounds in his right leg. The patient suffers from type II diabetes and is obese; his past medical history is arthritis, bronchitis and leg ulcers. He has decreased mobility and is not able to go to the treatment room at the health centre; therefore he has been referred to the district nurses team. In the first visit, the nurse, needs to assess the patient and the wound. He lives in a council house with his wife and six young children, he said he is monitoring his sugar level every day and they have been constant, patient has stopped smoking and tries to follow a healthy diet but he doesn’t do any exercise. He doesn’t have any social service coming to his house; his wife is the main carer. The assessment showed that the patient could carry out most of his daily routines on his own and only needs minimal assistance from his wife in things like washing his back or to put socks on. He has no hearing, verbal or cognitive problems and he wears glasses at all times. His wounds have been open for about five weeks; they looked clean and have no sign of infection. The nurse decided that in the next visit she will need to do a Doppler assessment. The nurse decided to do this based on his past medical history of previous leg ulcers, knowing that after six weeks a chronic wound that remains unhealed becomes an ulcer (Collins et al, 2002). She also did an assessment on the patient’s wound and surrounding skin, she assessed his weight and nutritional aspects and she took into account the patient’s diabetes. The fact that he has decreased mobility since the wound first appeared and the pain he was suffering were affecting his quality of life (Nursing Standard, 2005). The patient understood what a Doppler assessment meant and agreed to carry on with the procedure.

According to the RCN Guidelines (1998), all patients should have access to the Doppler assessment to help evaluate their ABPI (ankle-brachial pressure index) to ensure more thorough detection of any arterial problems. The key issue for the nurse was to recognize and to correct the underlying cause to enable the healing process (Journal of Community Nursing, 2007).

The next week the nurse went to visit the patient and do the Doppler assessment. The Doppler will measure the pulse strength in the feet and ankle and give an accurate diagnosis to determine the route of the leg ulcer. The result of the Doppler showed that the patient has a venous leg ulcer, a venous problem would mean that the valves in the veins are incorrectly working and backflow or blood remain in the feet and lower parts of the leg, causing oedema, nerve endings to die and a build up of toxins (Dougherty et al, 2004). The patient’s Doppler reading told the nurse that he was suitable for compression therapy. However, the nurse knew that the patient’s chronic condition, diabetes, can give abnormal readings due to obesity and old ulcers that may have damaged part of the venous system (, 2008). The patient’s readings were high, his A.B.P.I were 1 and 1.17 for the left and the right leg respectivily, this means that the patient was at the boundary for the compression therapy and may need to be referred to the vascular team (Leg Ulcer Care Pathway Form, 2006). The nurse wanted to make sure she was going to give the right treatment so she asked for advice from the leg ulcer specialist nurse. The specialist nurse advised her to put four layer compression bandages on the right leg of the patient and a hosiery for his left leg. The nurse, then, using her previous knowledge and experience decided to change the patient wound dressing, Allevyn adhesive, to a non-adhesive, non-medicated impregnated dressing to absorb and protect the wound (Autraman). Then, she put the four layer compression bandages on the patient’s right leg and the hosiery class II on his left leg. In making this decision the nurse used a rational approach, which uses logic, policies, protocols and guidelines (Hudson, 2005). According to government policy, the application of a compression bandage can only be applied by a trained and qualified member of staff. The incorrect application of compression bandages can lead to a deteroriation of the genaral condition of the leg (NHS, 2003).

Using a combination of rational and phenomenological theories, using the guidelines of the local trust, past knowledge and experience, the nurse was able to make a decision. This decision would be the best option to take regarding the patient condition and quality of life.

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From the rationalist perspective, the nurse used her experience to follow the nursing process, analysing the situation and taking the appropriate action, which leads to the best decision. According to Moore (1996), the nursing process should be rational and logical where decisions are made following a progression of events and circumstances, which involves deliberation and judgement. This process focuses on the actions of the nurse and involves assessment, planning, implementation and evaluation. Adair’s (1999) ‘five steps to decision making’ is another rational approach to the decision making process where the nurse will follow five very defined steps to make a decision. To compare these two rational models, it could be suggested that Adair’s theory would be increasingly useful in this case of decision making, it is less time consuming and easier to relate to the main focus points. However, it is essential to know that in decision analysis it is very likely to be making decisions about two different patients in a similar situation, and end up with two completely different optimun answers for each one (Harbison, 2001). These deductive approaches follow the principles of options, outcomes, values and likelihood (Lewis et al, 1999), which is a guide to assisst nurses, carers and other people to make decisions taking into account the patient’s principles and standards. Using past experience the nurse could use her knowledge of the patient’s other conditions along with his care requirements, to accurately decide the best intervention for him. The patient’s diabetes would contribute to the development of the leg ulcers and the fact that he was a heavy smoker (www.netdoctor.co.uk, 2008). Following the RCN Guidelines (1998) where treatment with long-strech elastic bandages for patients with an ABPI of 0.8-1.3 is recommended, the nurse applied the four layer system to the patient with evidence and knowledge that this will result in an effective outcome for both parties. However, the nurse’s experience in Doppler assessment wasn’t too extensive, this explains why she preferred to stick to guidelines and policies rather than her own intuition (Field, 2004). She also asked for advice from the specialist nurse in order to make the best decision, assessing the patient with all the possible information. Although the nurse made her decision based on a rational approach, Moore(1996) affirms that it is not possible for nurses in practice to make a rational decision based on all opportunities and possible outcomes. He also states that a decision is limited by the decision-makers intellectual capacity, level of knowledge and experience about the particular situation. This would suggest that all nurses need a degree of intuition to successfully use a rational approach when making any kind of clinical decision. In this particular case the nurse was able to combine the two approaches to increase the reliability of the decision. According to Benner’s (1984) ‘novice to expert theory’ there are five stages of clinical competence in which professionals make a transitional period throught each one as their education and experience increases. Benner suggests that a beginner has had no sufficient knowledge and experience of the situations in which they are expected to perform and that they can not be expected to make a rational or phenomenological decision effectively or competently. Benner states that beginners need to be taught rules that inform them of the clinical competence that is required for them to perform safely. From a phenomenological perspective, actions are followed by rational analysis, it takes a holistic view of nursing where experts use patterns as a whole (Harbison, 1991). In clinical practice it is evident that not all decisions are rational so they become phenomenological decisions. These non-rational decisions are also known as intuition. Intuition is the most common form of phenomenological decision making (Hudson, 2005). McCutcheon (2001) explain that intuition is based upon feelings, knowledge and past experiences. Intuition is not clearly rationalised and there is minimun theory to provide evidence to suggest that intuition is concrete and reliable. Evidence shows that intuition is based upon prior knowledge and reflection on prior events and that will contribute to an efficient analysis of clinical decision, ensuring care is effective (King et al, 1997). Benner (1984) states that intuition can only be achieved in the fifth stage of the Novice to Expert Theory and only once a professional has reached the expert stage they can use intuition effectively within their professional practice. Ubel et al (1997) suggests that both strategies of decision making should be learnt and that experience should be used to accurately decide whether the situation requires a rational or phenomenological approach. Harbison (1991) also states that decision making requires both analytical and intuitive process.

The nurse made her decision using both approaches, she made her decision using what is called the hypothetico-deductive approach. The hypothetico-deductive model involves both deductive reasoning and inductive reasoning (McAllister et al,1997). Studies have shown that decisions are not made by intuition but they are made using a cognitive strategy (Elstein et al, 2002), this means that the nurse will choose cues from the situation she is dealing with, then she will generate some hypotheses. She will then look for more cues and evaluates her different hypotheses, she can then come to a conclusion that will produce the decision (Hudson, 2005). In this case, the nurse has twenty years experience of nursing which give her sufficient confidence to make a decision, but she wasn’t very experienced in Doppler assessment, she has only been doing this for about six months. In the Doppler ultrasound assessment there are a number of factors that influenced the approach adopted by the nurse, these factors are experience, training, maintaining competency and practical issues (French, 2005). The nurse decided to ask a specialist nurse if she was going to take the best option for her patient because she didn’t have enough experience, she followed a rational approach. She followed an inductive approach when she decided to do the Doppler assessment early, using her intuition she knew that the leg ulcer of her patient won’t heal in six weeks, and because his diabetes, obesity and decreased mobility he may have venous leg ulcers and will need compression bandaging to help with his quality of life. This intuition is based upon feelings and these feelings a complex interaction of attributes involving experience, expertise, knowledge along with personality and environment (McCutheon et al, 2001).

Both approaches have strenghts and weaknesses. Intuitive approach is tricky as it can only be used by experts and is difficult to teach (Moore, 1996), Harbison (1991) also states that is almost imposible to teach intuitive judgement, professionals should be aware of the strengths and weaknesses of each perspective and would seek to link these in practice. As the nurse acquires more experience and education they advance through the remaining four stages until they reach the fifth stage, the expert in Benner’s (1984) model. Giving newly qualified professionals the confidence to make clinical decision, by increasing freedom and supportive atmosphere to the student in clinical decision, will improve the quality of care for patients (Benner, 1984). On the other hand, the phenomenological approach helps decision making in emergency situations where time is limited (Moore,1996). Harbison (1991) and Moore (1996) agreed that the phenomenological perspective used a holistic view of nursing care and the rational approach has a quantitive basis. Nurses can improve their ability of decision making and increase knowledge using both perspectives together (Chapman, 1994).

Communication is an important tool for nurses, communicating throughout the decision making process to all the people who need to know the key issues, to keep everyone informed of what is happening and to document what you are doing, so nobody feels left out ( Chapman, 1994).

To provide a good holistic care, professional judgement will not affect the care of the patient. Different opinions are formed about specific clinical decisions, based upon the fact that all professional’s experience of practice is different. A professional may have morals and values that are quite different to others, due to culture or religion they live or believe in (Jones, 1996). Ethical guidelines were established to eradicate these problems and to ensure that the patient receives as much information as possible so that an informed consent can be given. However, research shows that providing an overwhelming amount of options for patients to consider has a negative effect on their ability to make decisions (Ubel,1997). Providing too much unnecessary information causes the patient to become confused and forget much of what has been said. If a patient does not fully understand, their consent can not be classed as informed (Doh, 2006). Harbison (1996) argues that when the patient is unable to cooperate with the decision, the nurse should act on the patient’s best interest. Caring for a patient with venous leg ulcers where their life style has been changed due to pain, decreased mobility, work and body image, it is essential to keep the patient informed because a lack of information will have a negative psychological effect on their ability to take control and contribute to their own care (Moffatt et al, 2006). Ethics is about achieving the best for your patient and preventing them from harm (Tschudin, 1994). She goes on to state that strict ethical principles must apply to all people in oder to maintain a stable society. Ethics are provided in all health and social care settings to protect the patients and practitioners from harm and to reduce any moral and value differences creating an equal opportunity for everyone.

To conclude, we can state that without knowledge, experience and some kind of intuition, nurses wouldn’t be able to make accurate decisions or provide such knowledge that the patient can make a precise decision giving informed consent. In this particular case the patient needed a solution for his ongoing leg ulcers problem which was making him isolated and had decreased his quality of life. Using her experience, the nurse was able to make a rational decision in conjunction with some intuition to stop the patient getting in a worse condition and to, in a longer term, improve his quality of life.

Knowing that reflection upon your own knowledge and experience and how you connected the two, within practice, enables professionals to progress from ‘novice to expert’ (Benner,1984) and provides the basis for decisions to be more accurate and precise. Using rational and phenomenological perspectives together will lead to better decisions and this will help nurses to improve their ability to work in partnership with patients. Considering both approaches nurses can use tools given in both process to avoid poor quality decisions and increase knowledge and experience.

Good decision making also helps the relationship between professionals, leading to better multidisciplinary working.

Nurses always intend to benefit their patients, they must ensure throughout the whole decision making process that they make the best possible decision.

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