All nurses use clinical judgement to make decisions while caring for patients. These decisions have an effect on the actions of the healthcare professional and the delivery of health care the patient receives Jones and Beck (1996). It’s the nurse’s responsibility to make clinical decisions based on their learnt knowledge and skills. Simple decisions such as, would a bed pan or commode be more appropriate? To making quick, on the spot decisions, such as what steps to take if a patient began to rapidly deteriorate. Nurses rely on sound decision making skills to maintain positive outcomes and up to date care. Orme and Maggs (1993) identified that decision-making is an essential and integral aspect of clinical practice. Nurses are accountable for their decisions, therefore it is crucial that they are aware of how they make these decisions Muir (2004). This essay will discuss two decision making models, factors that may improve or interfere with clinical reasoning and decision making in patient centred care and how they vary across the different fields of nursing. The decision making models that will be discussed are Risk Analysis and Evidence Based.
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Risk assessment plays a major part in the process of supporting patients and it greatly helps to maintain safety in hospital settings. Its main purpose is not only to identify potential risks but also remove and prevent them. Assessment is considered to be the first step in the process of individualised nursing care Neno and Price (2008). Risk analysis provides information that is vital in developing a plan of action that can help improve personal health. It has the potential to decrease the severity of chronic conditions, helping the individual to gain control over their health through self-care RCN (2004). Not only is risk analysis for the patients safety but it’s also there to ensure staff safety Kavaler and Spiegel (2003). It is imperative that nurses use suitable risk assessment tools as a guide to enable them to make effective decisions. Once the tool has been implemented, using the gathered information and using their own clinical judgement, the nurse will then be able to provide the right safety precautions for patients Holme (2009). There are many different types of risk assessment tools available for patients and staff within the clinical setting. For patients there is the Waterlow score – risk of pressure sores and ulcers, the MUST tool – Malnutrition Universal Screening Tool, FRAT – Falls Risk Assessment Tool and Pain Assessment Tools are only to name a few and they are commonly used in clinical practice. Staff have Infection Control Assessments and Discharge Risk Assessments only to name a couple but they should be kept up to date and reassessed regularly Daniels (2004).
The pressure ulcer risk assessment/prevention policy tool, is frequently used in clinical practice. Pressure risk-assessment tools have been described as the backbone of any prevention and treatment policy Waterlow(1991). The Department of Health set annual targets for an overall reduction of pressure ulcers by 5-10% over 1 year (DoH, 1993), so it is vital that nurses accurately determine which patients are at risk of developing pressure ulcers.
A pressure ulcer is an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction or a combination of these EPUAP (1998). The intention of the Waterlow pressure sore risk assessment is to recognise service users who are highly at risk of developing pressure sores, to avoid them becoming worse and/or even developing them at all, to serve as an early predictive index before the development of pressure damage Nixon and McGough ( 2001). It is imperative that patients are assessed using this tool, especially patients with Intrinsic risk factors such as restricted mobility and /or are confined to their bed for long periods of time, patients with poor nutrition, elderly patients, patients with underlying health conditions such as diabetes and patients who are urinary incontinent and bowel incontinent are also highly at risk of developing pressure sores, this due to the moisture, moist skin can be weak and susceptible to breakdown Andrychuk (1998). According to the NICE clinical guideline 29 (2005) pressure ulcer grades should be recorded using the European Pressure Ulcer Advisory Panel Classification System. There are four stages that pressure ulcers are graded at and it is down to the nurses own clinical judgement to decide what stage the ulcer is. Depending on the grade of the pressure sore, it will depend on the type of mattress that will be needed. There are factors to be considered before selecting a mattress for the patient which include, making sure the mattress does not elevate the patient to an unsafe height and to ensure the patient is within the recommended weight range for the mattress NICE (2005).
Using their learnt skills, experiences and own clinical knowledge, nurses have to decide what dressings should be used in the treatment of pressure ulcers. They have to take into consideration the grade of the sore, any manufacturer’s indications for use and contraindications, previous positive effects of certain dressing and preference for comfort or lifestyle reasons Bouza et al (2005). Specially designed dressings and bandages can be used to speed up the healing process and help protect pressure sores such as hydrocolloid and alginate dressings which will be used at the nurse’s digression NHS Choices (2010).
Nurses should always be aware of any potential risk factors that may worsen or add to the development of pressure ulcers when using any pressure risk assessment tool. The nurse will have to decide the frequency of re-positioning the patient, implementing a turning chart to keep times and dates documented and to communicate to other members of staff what time the patient needs turning. This involves moving the patient into a different position to remove or redistribute pressure from a part of the body Walsh and Dempsey (2010). By analysing the evidence on the effectiveness of repositioning this can help to reduce patient suffering and improve their quality of life, lighten the work load of staff and help reduce the financial burden on the health service Luoa and Chub (2010).
In paediatric nursing, a child is to be assessed within six hours of being admitted and then reassessed daily. Most paediatric pressure ulcer risk assessment scales were developed using clinical experience, or by modifying adult scales Bedi (1993). The Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale was developed using detailed paediatric inpatient data Willock et al (2008). It is a clinical tool designed to help nurses assess the risk of a child developing a pressure ulcer, it uses a scoring system that takes things like mobility, equipment, haemoglobin levels and temperature into account and guides the nurse as to what interventions need to be put in place, such as what type of mattress or dressings will be needed.
In learning disability and mental health nursing, a range of pressure sore assessment tools are used such as the Norton, Braden and Waterlow risk assessment scales, these are mainly used for patients who are not very mobile as in the adult field. Nursing is more concentrated on their patient’s psychological health O’Tuathail and Taqi (2011).
It is the nurse’s duty to provide the best possible care for their patients and this involves using Evidence-based practice. EBP enables the nurse to make decisions about patient care based on the most current, best available evidence. It allows the nurse to provide high quality care to patients based on knowledge and research Rodgers (1994). Principles of evidence-based practice and the crucial elements involved in the process are explained by Cleary-Holdforth and Leufer (2008) in five steps. Steps are there to equip nurses with the necessary knowledge and skills to use evidence-based practice effectively and to make positive contributions to patient outcomes. The five steps Ask, Aquire, Appraise, Apply, Analysis and Ajust are to simply guide healthcare professionals in making effective clinical decisions when problem solving.
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Early Warning Score (EWS) is an evidence based method. Carberry (2002) identifies that the purpose of EWS is to provide nursing and medical staff with a physiological score generated from recordings of vital signs. NICE Clinical Guideline 50 (2007) suggests that physiological track and trigger systems should be implemented to monitor all adult patients in acute hospital settings, providing guidance on the standardization of EWS. Physiological signs that should be monitored and recorded are heart rate, blood pressure, respiratory rate, oxygen saturation, temperature and level of consciousness. Vital signs should be recorded upon admission, at regular intervals during a patient’s stay and also before, during and after certain procedures Castledine (2006) and the frequency of monitoring, if abnormal physiology is detected should increase. EWS uses a scoring system 0, 1, 2, and 3 and colour codes white, yellow, orange and red, number 3 and the colour red being the highest risk indicators Morris and Davies (2010).
Nurses should adapt to following guidelines the Early Warning Score offers, to help make clinical decisions that are best for their patients. Factors that may improve or prevent effective decision making while using the EWS could be down to capability, knowledge and ignorance. If health care professionals are well able and confident in recording and documenting patient’s vital signs, then any changes can be observed and prevented or dealt with quickly. The EWS implementation adds automated alerts hours before a rapid response would be initiated and can decrease treatment delays by up to three hours Subbe et al (2003). It only takes one nurse to lack competence when using the EWS, therefore putting patient’s life’s at risk.
Early Warning Score is also used in the Mental Health and Learning Disability fields of nursing although it may not be used as often as in Adult nursing, it is imperative that patients who are physically or mentally unwell, require monitoring of their vital signs in an acute setting. Nurses may have to use their knowledge to improvise different ways of obtaining vital signs from some patients with learning disabilities or mental health problems, such as turning it into a game or distracting them especially if they lack the mental capacity and are unwilling to comply Hardy (2010) Medication can have serious effects on a patient’s health. Indications of these effects may be noticed in their EWS, combined with the knowledge and clinical judgement of health care professionals NIMH (2008) . If the EWS tool is not used as it should be in these fields then it will be hard for the health care professionals to obtain the needed evidence to make accurate clinical decisions.
In the child field of nursing a similar tool to the EWS is used called PEWS, Paediatric Early Warning Scores. There are currently four PEWS charts used within the NHS for different age groups, 0-11months, 1-4 years, 5-12years and 13-18 years, the difference being the ranges for children’s vital signs NHS (2013). A key factor that may hinder accurate PEWS scoring could be due to the fact the child is scared when it comes to checking their vital signs, also very young children can be unwilling or fidgety Kyle (2008), this is where the nurse would have to use their knowledge to overcome such problems. The nurse could make it fun for the child, explain the equipment and what they are going to do and why. It is vital that the nurse gains consent from the child’s parent before carrying out any procedure. It is important that the family play an important role in the care of the child DOH (2001).
I have learnt various things while researching into the chosen decision making models and methods. I have been made aware of potential risk factors that may arise while using both tools in all fields of nursing and what could be done to prevent them. I feel confident in looking out for any risks involving the EWS and Pressure ulcer risk assessment tools while out in practice and believe that using these tools correctly can ultimately save lives.
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