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Clinical Decision Making in Nursing

Every single day, nurses experience the need to make crucial decisions within the nursing process. Nurses are charged with the responsibility of assisting their patients through the recovery process and thus handle varied problems that require their critical decisions. Decision-making is thus an important aspect of the nursing profession as its effectiveness determines the outcomes in clinical health care. Hence, nurses have to think critically and make decisions that are acceptable within the nursing protocol and can result in positive outcomes. This paper, therefore, seeks to undertake an analysis of the clinical decision-making process using a case study scenario.

The case scenario

The case involves an eighty-two years old woman, Mrs. A, admitted to the high acuity unit four days ago from PAR after undergoing surgery to correct her left hip. In the case is also a nurse, Kathy, who is resuming her duties after a vacation. A report from the nurse on the night shift informs Kathy that Mrs. A had been restless throughout the night and they had to put her in a restrained chair fearing that she might fall while climbing from the bed. Kathy finally gets to meet Mrs. A. From her physical appearance, Mrs. A looks confused, her hair sticking out wildly in all directions, and she is crying out for help to get her out of her position. Mrs. A is also stinking urine, the greeting smell that first met Kathy as she approaches Mrs. A.

Another figure in the picture is Gladys, Mrs. A’s daughter, who provides Kathy with information on Mrs. A’s history. Kathy first thought Mrs. A’s confusion was just normal post-ops that elderly experience, but soon realized something must be wrong after listening to Mrs. A’s history. Kathy’s clinical decision-making starts from this point as discussed below. Another important figure in the case is Adam, Kathy’s colleague, who collaborates with Kathy in the decision-making process.

Kathy’s decision-making process

Foundational knowledge

Knowledge is a very important component of the clinical decision-making process. The effective clinical decision-making process requires a nurse to acquire knowledge actively from the patient, and the situation, which blends with knowledge of the nursing profession and knowledge of individual self to result in a significant decision (Paterson & Gillespie, 2009). The aspects of knowledge in Kathy’s decision-making process can be best discussed using Paterson’s Clinical Framework as follows.

Context
Adopted from Paterson & Gillespie, 2009
  • Knowing the self: This reflects knowledge of one’s strengths and weaknesses including personal skills, beliefs and values (Paterson & Gillespie, 2009). In the case scenario, Kathy recognized her lack of experience in handling cases similar to Mrs. A’s, but also remembered having observed her colleague deal with difficult family members successfully. Reflecting on her colleague’s earlier experience, Kathy composed herself and handled Gladys in a professional manner that also made her acquire important information about the patient’s history.
  • Knowledge of Profession: Knowledge of profession means assimilation of knowledge of standards of nursing practices as well as nursing skills, competencies and roles in the decision-making process (Paterson & Gillespie, 2009). In the case scenario, the way Kathy handled Mrs. A proves her knowledge of nursing skills, competencies, and roles. When she first met, Mrs. A, she introduced herself in a manner meant to reassure her, just as it is required of every nurse when handling patients. Her first encounter with Gladys also proves that she knows the skills required to deal with family members of patients during emergencies. Besides, her concern for Mrs. A’s situation proves that she is a competent nurse who understands the ethics of her profession.
  • Knowledge of the case: This refers to knowledge of patient populations including pathophysiology, existing patterns in typical cases, and response patterns (Paterson & Gillespie, 2009). Kathy’s utilization of knowledge of the case in her decision-making process comes out clearly during her discussion with Adam. Initially, Kathy thought that Mrs. A was demented, but ruled this out after receiving the knowledge of Mrs. A’s history from Gladys. She brings in the possibility of anesthetic drugs as the probable cause of post-op confusion but also rules it out arguing that its effects usually wear off soon yet Mrs. A’s situation was getting worse. Another possibility in Kathy’s list is that Mrs. A could be delirious. She first argues that the most common cause of delirious is medication, but Mrs. A had not received any pain medication last night hence the chance is minimal. She then jumps to a conclusion that Mrs. A’s confusion is a result of pain and lack of sleep. Another important knowledge of the case that helped Kathy in her decision-making process came from Adam. He suggested the possibility of Mrs. A having a Urinary Tract Infection based on the smell of her urine and another possibility of constipation given that Mrs. A was oozing stool.
  • Knowing the person: this reflects knowledge of the patient’s history in relation to his/her present state of health (Paterson & Gillespie, 2009). In the case scenario, the first knowledge Kathy received about Mrs. A was that she was diabetic. However, the most important information about Mrs. A’s past health came from Gladys. From Gladys’ report of Mrs. A, Kathy got the impression that prior to her hip surgery, Mrs. A was a vibrant and organized old woman, the information that made her realize something was wrong somewhere and hence the urge to dig deep into the problem.

Cues in the process

In the clinical decision-making process, nurses use prompts from various sources to guide them in their decision-making (Potter & Perry, 2009). These prompts are referred to as cues in Paterson’s clinical framework. In the decision-making process, cues are collected from various sources including clinical observation of patients, clinical reports, family members of patients, laboratory assessments, healthcare professionals, and significant others among other sources (Paterson & Gillespie, 2009). In Kathy’s decision making process, there were five significant cues. The first cue was from a clinical shift report by the nurse on night shift that gave Kathy a snapshot idea about Mrs. A’s situation. The second cue was her personal observation of the patient as she went to attend to her. A report about Mrs. A’s past health status as presented by a family member, Gladys, formed the third cue in Kathy’s clinical decision-making process. From this report, Kathy was able to realize that something is seriously wrong with Mrs. A’s current health hence the need to find where the problem lies. Another important cue in Kathy’s decision-making process was statement from a fellow healthcare professional, Adam. From his comments, Kathy saw the need to examine Mrs. A for UTI and impaction. Intuition was another important cue in this process. Intuition in this scenario is evident in Kathy’s attempt to knowing the case. Finally, the laboratory results provided the last cue in Kathy’s decision-making process. If I were Kathy, I would have also used PAR where Mrs. A was first attended to as one of the cues to aid in understanding Mrs. A’s health.

Clinical reasoning skills used by Kathy

  • Identifying Assumptions: This skill refers to the ability to identify information taken for granted or presented as fact without evidence (Alfaro-Lefevre, 2009). In the case scenario, Kathy was able to identify her prior assumption of Mrs. A’s condition. After getting information about Mrs. A’s past health, she realized she was wrong in assuming that Mrs. A was demented. This triggered her to wonder what could be wrong with Mrs. A.
  • Assessing systematically and comprehensively: Kathy used this skill while trying to identify the root causes of Mrs. A’s confusion. After her discussion with Adam, Kathy started by first administering some pain medication to Mrs. A. She then collected Mrs. A.’s urine specimen to send off for laboratory examination. She also checked Mrs. A. for impaction and gave the necessary medication. Later on, she examined Mrs. A’s blood glucose. All these were aimed at trying to establish the root cause of Mrs. A’s confusion in a systematic and comprehensive manner.
  • Distinguishing normal from abnormal and identifying signs and symptoms: This skill refers to the ability to analyse patient’s data to be able to separate what is normal from what is abnormal and identify the specific problem reflected in the signs and symptoms of abnormal occurrences (Alfaro-Lefevre, 2009). When Mrs. A’s blood glucose level gave a reading of 3.3 mmol/L, Kathy was able to tell that this is abnormal and immediately started Mrs. A on something to raise her blood glucose level. After a chat with Adam, Kathy was able to identify this as one of the probable causes of Mrs. A’s confusion and even discussed it with Mrs. A’s doctor who after listening to Kathy’s concerns reduced Mrs. A.’s Diabeta to 2.5 mg from 5mg.
  • Making Inferences: Making inferences refers to the ability to use logic interpret patient’s cues and make deductions concerning the situation at hand (Alfaro-Lefevre, 2009). Kathy used this skill when discussing Mrs. A’s probable problem with Adam. Kathy first thought Mrs. A. was demented, but ruled this out after listening to her history. She then considered the possibility of anaesthetic drug effects, but also ruled this out arguing that such symptoms fades off after a while Mrs. A was getting worse. She also considered the possibility of pain medication, but also ruled this out, as Mrs A had received none. She then concluded that Mrs. A’s confusion is probably due to pain and lack of sleep.

From these clinical reasoning skills, Kathy was able to make two important judgements: that something was wrong in Mrs. A’s situation and that she needed to dig deeper into the problem to find information that could help her come up with a solution that would help Mrs. A. get better.

If I were Kathy, I would also consider distinguishing relevant from irrelevant as an important skill in this scenario. This case had a lot of information from many cues hence the need to sort them out and work with relevant information only.

Kathy’s decisions

Following her judgment, the first decision Kathy made was that she needed to do something about Mrs. A’s condition. Her next decision was to inform a colleague, Adam, who helped her with some important ideas on the case. Even after her discussion with Adam, Kathy made a decision to act on their concerns, which also culminated in her decision to involve Mrs. A’s doctor.

Kathy’s evaluation of outcomes

In Paterson’s framework, evaluating outcomes refers to assessing the effectiveness of the decisions made (Alfaro-Lefevre, 2009). Kathy’s process of evaluating outcomes started right after bathing Mrs. A up to the end of her block of shifts. After cleaning Mrs. A and tiding up her bed, Kathy asked Mrs. A if she felt better; a clear sign of evaluation of outcome. She also evaluated outcomes of her action after performing the first rounds of remedial care, which included giving Mrs. A some drugs to reduce her pain and her constipation. She was able to notice that these had a positive effect, but still needed to do more. She carried out another evaluation in the evening and was pleased with the outcomes. At the end of her block of shifts, she was sure she made the right decision and that Mrs. A was in the right path to recovery.

The contextual variables in Kathy’s decision making process

Kathy’s decision was influenced by many contextual variables. At the micro-context, Kathy fostered a good relationship with the patient and was able to understand Mrs. A in her situation. At the meso-context, Kathy consulted and collaborated with her colleague in the decision making process. Finally, at the macro-context, Kathy’s decision was influenced by a report from the patient’s family. Time factor was also another contextual influence, as Kathy had to come up with a decision that could aid towards helping Mrs. A to get better quickly.

Ethical dimension of Kathy’s decision

Kathy’s decision-making took the dimension of both relational and principle-based ethics. The relational dimension was provided through Kathy’s friendly relationship with Mrs. A and her family while principle-based ethics arose from Kathy’s adherence to the requirements of her profession. The most applicable ethical principle in Kathy’s decision-making is beneficence. Beneficence as an ethical principle requires that nurses and healthcare providers alike take the necessary interventions to benefit patients and avoid more harm (Alfaro-Lefevre, 2009). The main purpose of Kathy’s decision-making process was to restore Mrs. A’s health hence a clear demonstration of beneficence. Apart from beneficence, Kathy also utilized the ethical principle of veracity as she never lied at any point during her decision-making process, but rather told the truth and even explained her actions to the patient’s family. For instance, when Gladys found her mother in a restrained chair and complained about her mother’s state, Kathy simply explained to her why she had to be restrained and told her that it was within the hospital restrain policy to put patients under minimum restraint to avoid more harm. Ethical decision making rests on ethical reasoning. From this case scenario, Kathy utilized ethical reasoning while trying to reason out the possible underlying causes of Mrs. A’s condition. Kathy does this by proposing a medical problem and comparing its symptoms to Mrs. A’s situation to see whether she falls in that category and proceeds to rule them out until she is left with the most definite cause of Mrs. A’s problem

Comparison of Kathy’s decision-making processes to my own

Kathy’s decision-making processes provide the most appropriate example for nurses to learn. As a nurse, I have at times made decisions without utilizing information from all cues and foundational knowledge hence ended up with decisions that did not yield positive outcome as I expected contrary to Kathy’s decision making process. My decision-making processes, however, have some similarities to Kathy’s decision-making process. First, beneficence is remains the core principle in just like in this case scenario. Second, I always consult my colleagues in the decision making process just like Kathy did. Finally, at the end of my decision making process, I always evaluates outcomes and tries to highlight my weaknesses for the failed decisions.

References

Alfaro-Lefevre, R. (2009). Critical thinking and clinical judgment: A practical approach to outcome-focused thinking (4th Ed.). St. Louis: Saunders.

Paterson, L. B. & Gillespie, M. (2009). Helping novice nurses make effective clinical decisions: The situated clinical decision-making framework. Nursing Education perspectives, Vol. 30 (3), pp. 164-170.

Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th Ed.). St. Louis: Mosby.