Essay title - Nursing Making Experience
The aim of this assignment is to discuss a decision made in practice, relating a nursing intervention and to identify the decision making strategy, by recognising the potential challenges. In accordance with the NMC (2004) code of professional conduct on confidentiality clause 5, the name of the service user shall be a pseudonym of Mr X. Mr X was admitted under the section 3 of the Mental Health Act (1983), with a diagnosis of depression on an acute admissions ward at an outer London Mental Health Unit. The reason for choosing Mr X as an example is due to my involvement in the decision making process made during my recent mental health placement. Based on my recommendation, Mr X was placed on close observation (1:1) for his own safety.
During an informal conversation, Mr X expressed some concerns regarding his mental state. Being the allocated student nurse to Mr X and other three service users, I was able to encourage him in ventilating his feelings. He claimed to be having active suicidal thoughts with plan, as feeling of worthlessness and pessimistic thoughts about the future have been intensified. According to Harrison (2004), it is not possible to observe patients` thoughts directly and the clinician would not know these thoughts are directly without asking the patient. For this reason, it was vital to rely on Mr X responses and feelings. This led to believed that Mr X poses a serious risk to himself. Therefore, in order to protect Mr X from harming himself, a suggestion was made to my mentor that Mr X should be placed on close observation (1:1) and this decision was agreed by the interprofessional team following an extended risk assessment.
The rationale for placing Mr X on close observation is derived from my past and personal working experience and knowledge as a health care assistant on acute admissions ward. As from my experience, patients with active suicide plans do make an attempt to commit suicide, while on the ward. Barker (2003) emphasised that a suicide attempt is very difficult to predict, but a risk assessment will direct the provision of an appropriate level of protection. Furthermore, the NMC (2004) clearly states that a registered nurse must act to identify and minimise the risks to patients. It appears that the risk assessment played a central role in the decision making process. To support this view, Thompson & Dowding (2002) asserted that one of the ways in which judgements of risks have been formalised is through the use of risk assessment tools.
Research suggests engagement and psychological support are the key nursing strategies for reducing risks. Therefore, the 1:1 observation would be the most appropriate nursing strategy for Mr X, in order to comply with the NMC (2004) guidelines and moreover, Clinical governance lay emphasis to implement subsequent measures to reduce those risks. The management of risk is an important part of everyday nursing practice and underpins many nursing decisions (Braine 2006). As a result of this, it can be argued that the decision was made on experiences, theoretical and personal knowledge, and evidence base practice. According to DOH (2007) any risk-related decision is likely to be acceptable if it conforms to relevant guidelines and it is based on the best information available. As long as a decision is based on the best evidence, information and clinical judgement available, it will be the best decision that can be made at the time (DOH, 2007).
Effective clinical decision-making is an essential component of professional nursing practice and decision-making is a process nurses use to manage a range of information from diverse sources to make professional clinical judgements (Jasper, 2006). According toThompson et al (2004) effective clinical decisions is the most important factor affecting the quality of care. Considering the statement made by Thompson et al (2004), it implied that examining judgements in nursing is vital, as they have an effect on decisions taken about patients` care. Harvey (2001) suggests decisions may be poor because the judgements on which they depend are inaccurate or because individuals combine different judgements inappropriately. Therefore, a key issue for nurses is ensuring judgements are as accurate as possible.
Dowding & Thompson (2004b) claimedthat when making decisions nurses, like all people are subject to uncertainty, error, and heuristic short-cuts. Unfortunately, it has shown that these heuristics are fallible and can introduce unhelpful bias into decision-making. Furthermore, Jasper (2006) asserted that intuitive actions may be difficult to explain, even when they lead to beneficial outcomes, in contrast, analytical processes can be demonstrated to others if necessary. This led to believe that nurses are better protected if they can show their decisions are based on care pathways or clinical guidelines. According to DOH (2007) best practice involves, making decisions based on knowledge of the research evidence, knowledge of the service user’s own experience and clinical judgement. Therefore, it could be argued that by effectively combining research evidence with clinical expertise in a collaborative approach, nurses can implement the highest standards of evidence-based practice.
A research conducted by Warr (2006) concluded that the respondents did not think there were any skills unique to clinical decision-making, however, the greatest emphasis was placed upon knowledge and experience gained over an extended period of time through clinical practice. In addition, according to Bakalis (2006), nurses' competence is a key factor in clinical decision-making, and it comes from their professional knowledge, skills and experiences. In his study of nurses' perception of clinical decision-making, he also concluded that knowledge and experience place an important role in effective clinical decision-making. The knowledge a nurse brings to the diagnostic task plays a critical role in determining how the problem will be interpreted. The knowledge that nurses store in their memories in the form of concepts, schema and scripts is retrieved when needed (Thompson et al, 2004).
Clinical experience is identified as being essential for effective clinical decision making (Benner (1987), cited in Jasper, 2006). Bakalis (2006) stressed that the experience level of the nurse has a profound effect on the decision-making process. He also made reference to (Benner (1987) experimental study examining differences in the way that novices and experts make decisions. The findings concluded that the experts often used less information in making a more accurate diagnosis and generated more alternative actions, were more specific in evaluating alternative actions and developed better nursing plans than novices. On the hand, Thompson et al (2004) emphasised that although Benner's work has provided insight into the nature of expert nursing practice, it fails to give details of how information is processed to inform accurate judgements. Therefore, it is important that inexperienced nurses work with experienced or expert nurses to help them develop this skill either directly or indirectly through the mentorship process.
In conclusion, clinical decision making is a complex process. Nurses use a range of information to make judgements and these judgements can be challenge, whatever the outcome. Competency, knowledge and experiences increase the cognitive resources available for interpretation of data resulting in more accurate decision making. Expert or novice practitioner, the patient’s care and needs must always be paramount.
Reference Lists
- Barker, P. (2003), Psychiatric and Mental Health Nursing, The Craft of Caring, London, Arnold.
- Bakalis, N. (2006) `Clinical decision-making in cardiac nursing: a review of the literature`, Nursing Standard. 21, (12), P 39-46.
- Braine, M, E. (2006), `Clinical governance: applying theory to practice`, Nursing Standard, 20 (20), P56- 65.
- Department of Health, (2007). Best Practice in Managing Risk [Online], London, Stationery Office. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_076511 [Accessed 12.11.2007].
- Jasper, M. (2006), Professional development, Reflection and Decision- Making, Oxford, Blackwell.
- Harrison, M. (2004), Acute Mental Health Nursing, From Acute Concerns to the Cable Practitioner, London, SAGE
- Thompson, C. McCaughan, D. & Dowding, D (2004), `Strategies for avoiding pitfalls in clinical decision-making`, Nursing Times, 100 (20), P 40.
- Thompson, C. & Dowding, D (2002), Clinical Decision Making and Judgement in Nursing, London, Churchill Livingstone.
- Warr, J (2006), `Clinical decision-making and the consultant nurse role`, Nursing Times, 102 (39).
n order to appreciate the potential for evidence-based practice in nursing we need to understand the nature of the decisions and uncertainties that nurses face. Having this information to hand helps in the development and implementation of decision support tools (such as guidelines). It also helps us to generate research knowledge that is actually useful for clinical practice.
A research conducted by Warr (2006) concluded that the respondents did not think there were any skills unique to clinical decision-making, however the greatest emphasis was placed upon knowledge and experience gained over an extended period of time through clinical practice.
was published in Nursing Times; 102: 39, 26th September 2006, Warr, Jerry. (2006) Clinical decision-making and the consultant nurse role.
Standard seven http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009598
Preventing suicide safety on wards is improved to reduce access to the means to commit suicide. Inpatient suicides are twice as frequent as suicides in prison, and this suggests that access to means and the lack of supportive observation for people at risk in hospital is a factor in their death.
Research suggests engagement and psychological support are key nursing strategies for reducing risk, therefore the 1:1 observation would be beneficial for Mr X. Empathy, active listening and involvement in care planning can reduce self-harming behaviour (Jones, 2000).
Engaging the patient in a risk assessment before formulating a care plan is, therefore, a nursing priority. Such an assessment is informed by a knowledge of factors relating to increased risk of suicide (Box 1).
DOH N NSF 4 MHM Lay emphasis, involve service users and their carers in planning and delivery of care
By effectively combining research evidence with clinical expertise in a collaborative approach, case teams will be implementing the highest standards of evidence-based practice.6
Best practice involves making decisions based on knowledge of the research
evidence, knowledge of the individual service user and their social context,
knowledge of the service user’s own experience, and clinical judgement
Effective clinical decision-making is one of the most important components of professional nursing practice. It consists of gathering, processing and prioritizing critical patient information to choose and implement nursing actions and evaluate the results. As White (2003) mentioned, decision-making is the clinical function that differentiates nursing professional staff from technical ancillary staff [4]. Our results suggested that there are some barriers to effective clinical decision-making. According to participants, nurses' competence is a key factor in clinical decision-making, and it comes from their professional knowledge, skills and experiences. In a study of nurses' perception of clinical decision-making to patients in pain, Baker (2001) concluded that knowledge and experience place an important role in effective clinical decision-making [15]. Also Orielly (1993) confirmed, experience and knowledge are two major factors affecting decision-making [5]. But Louri and Salanteral (1998) reported that the model each nurse uses for decision-making depends mainly on his\her task and context of the situation but not to the level of his\her knowledge and experiences [16]. However the participants in our research emphasized that it is "proper use" of knowledge and skills that makes the decisions effective. In the other words, competent decision-making is more than the simple application of theoretical knowledge or performing technical skills, but it requires integrating knowledge, skills and experiences and also a close relationship to the patients to make a deep "understanding of the clinical picture" [4] or "seeing the big picture" [17]. According to the participants in this research, self-confidence is considered a vital factor in effective clinical decision-making. Those nurses having more confidence have better control over their work, make more efficient decisions and intervene more independently [4]. Self-confidence has a close relationship with self-efficacy. Roberts et al. (1981) considered the terms self-efficacy and self-confidence interchangeable. Self-efficacy defined by Bandura as a situation specific self-confidence that indicates the level at which one believes one can successfully perform a task [18]. Bandura's research (1997) has also shown that the individual's self-efficacy may be more significant to task performance than his actual skills [19]. Self-confident persons have an internal locus of control, and believe in their ability to influence results [20]. A meta-analysis of more than 80 studies also revealed that employees with high levels of perceived control at work were more satisfied, committed, involved and motivated [21]. Therefore it appears that self-confidence may be an important factor in effective decision-making [22].
Although self-confidence results in better decision-making, about 40% of participants in this research complained of the lack of self-confidence among nurses and nurse managers and considered it as one of the major inhibitors to effective independent decision-making by nurses. The lack of self-confidence in nurses was also confirmed in the studies carried out by Madjar (1997), Fulton's (1997) and Baker (2001) [23,24,15].
Also environmental factors, amount of relevant professional knowledge and clinical experience, collegial relationship and staffs' interactions with their managers play an important role in nurses' self-confidence and effective clinical decision-making [15]. It seems that nurses have internalized beliefs about their own inferiority [25]. Also, their doubt in their own knowledge, ability [24], and competency have decreased their self-confidence and made them relinquish the authority to those perceived as being better. The findings indicate that variables related to organizational structure and its culture have influenced the nurses' decisions. Although the organizational variables could both enhance or inhibit the effectiveness of staff decisions, participants in this research implied that these variables were among the major inhibiting factors having decreased nurses' perceived control over their work. These variables also have decreased their self-confidence, which in turn, has decreased their participation in clinical decision-making. Findings indicate that the levels of authority, organizational climate and the nursing system used on the units affect the participation of nurses in decision-making. However, the cultural context of the organization seems to have the most inhibitory effect in this regard. Nurses wanted to have authority to make decision related to duties within the nursing domain. Although they implied that job description and official rules were the sources of their diminished authority, the culture of nursing was highly task-oriented and physician controlled. Factors such as unbalanced nurse-patient ratios, heavy workloads, and expectation from nurses to only execute the doctors' orders resulted in a diminished relationship with patients and had them choose a functional and task-oriented nursing system. These results confirmed the findings of Baker (2001) who reported that lack of time and heavy workload negatively affected decision-making, because nurses cannot comprehend patients' requirements [15].
Although Krairikish and Anthony (2001) implied that structure and setting process have little influence in decision making related to nursing practice [26], it seems that lack of time for completion the routine tasks has resulted in little time for nurses to participate in decision-making and independent nursing interventions, as confirmed by Fulton (1997). Perhaps it is for this reason that Anthony (1999) has suggested that authority has a weak relationship with the nurses' actual decision making [27]. In this research it was discovered that "being supported is an important predictor of nurses' effective participation in clinical decisions. In a study on benefits and outcomes of staff nurses' participation in decision-making, Krairikish and Anthony (2001) reported that nurse managers' leadership had little effects on staff nurses' participation in decisions [26]. However, nurses in our study implied that unsupportive management was a barrier to effective clinical decision-making. Of course the leadership in the Krairikish and Anthony study was conceptualized as the presence and competence of the manager, while present study emphasizes on the support of the manager. Nonetheless the role of the manager appears to be central to nurses' decision-making. However, heavy workload, poor staffing, low income, not having power for decision-making and partiality of managers with doctors in their conflicts with nurses, were the most causative factors in feeling of being unsupported. These findings have also been confirmed by other researchers [28-30,5].
Nurses perceived their managers as being unsupportive. Those nurses who directly care for patients chose patient care as their highest value, but they saw the employing institutions and the managers ignoring their welfare. They expect their managers to provide them with 'facilities for care,' financial and emotional support' so that they can participate in patient-related decisions and provide quality care for their patients. According to Macphee and Scott (2002), although all factors and working conditions are not under the control of managers, emotional supporting of nurses can decrease the pressure on them [31], increase feelings of self-confidence and enhance their effective participation in decision-making.
The participants emphasized the critical role of nursing education in preparing nurses to make effective clinical decisions. As White (2003) argues, the mission of undergraduate nursing education is to prepare nurse generalists who will be able to provide care in a variety of clinical environments [4], but depending on the educational related variables such as educators and role models, content of the curriculum, methods of education and evaluation, this quality may be enhanced or inhibited. Many authors have emphasized the importance of nursing educators and educational institutions in development of nurses' clinical decision-making skills [15,32-34]. However approaches to the preparation of nursing students for a successful transition into the workplace have been found to be ineffective. According to the participants "Role models," "Content of curriculum," and "Methods of education" all played an inhibiting role in effective clinical decision-making. The curriculum seems to contain a vast range of theoretical content, mostly based on medical model, and faculty members feel pressure to find a way to present a massive amount of content necessary to facilitate passing of the final examination (which is equivalent to licensing examination). They spend more time on theoretical education; so, there will be less time for practical and student-centered learning and developing students' clinical decision making skills. Their educational methods are teacher-centered. They use lectures as the most important method of education. Therefore the manner in which nurses are trained is rigid, controlling and encouraging conformity, passivity, dependency and subordination. In a study of difference between enabling and empowering, Espland and Shanta (2001), argue that empowering is an interpersonal process which increases students' control on their practice, while enabling encourages dependent behavior in students. They believed that, faculty members who enable students do not encourage their development of problem-solving [and decision-making] skills. Such educators decrease students' self-esteem, and negatively affect their self-concept and self-confidence [33]. Therefore nurses do not try to make independent decisions and rely mostly to executing the doctors' orders.
The findings of the current study indicate that clinical decision-making is a basic social process involving some individual and environmental variables. Precise review of these variables as well as findings and data obtained during the analysis stages of this study suggest the existence of interactive relations among the variables. These interactions are presented in Figure 1. As this model has shown, although feeling competent is important, self-confidence is a basic requisite for making effective clinical decisions. Organizational structure, supportive or unsupportive management and nursing education also have facilitating or inhibiting effects in this process.
Although Benner's work has provided insight into the nature of expert nursing practice, it fails to give details of how information is processed to inform accurate judgements.
This is due in part to the research methods used - predominantly observation of practice and interviews.
