There are number of clinical reasoning and decision making models used in nursing practice, however this essay will discuss evidence based-practice and the ethical/legal models. Each model will be discussed in turn, first providing an overview, explaining its use and aim in healthcare. Then an example of method use will be discussed. The relevant factors that may help or hinder the use of the method will be then be considered. The final section will explain and illustrate how decision making is different across all fields of nursing and how this may impact on the patient experience. Finally the essay will consider how the two models and methods are used in practice to deliver patients centred care and how future practice it may be enhanced from learning gain through researching this essay.
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According to Wickens et al (2004), CR and DM are refer to times when nurses and other health care professionals use their cognitive processes and critical thinking , previous experience and protocols to understand a patient’s problem. She added that the nurses then plan and implement interventions, evaluate the outcomes and reflect and learn from the process.
Evidence based practice (EBP) is a systematic approach to clinical decision making, within the health care sector. It combines scientific evidence, clinical experiences as well as patient preferences and values about care and treatment (Melnyk and Fineout-Overholt, 2005). This is used in nursing practice to provide guidelines for nurses. For example, the National Institute for Clinical Excellence (NICE) (2008), guidance which provides an overview of how conclusions can be drawn in an attempt to identify the most appropriate action. Rubin (2007) however, summarises two disadvantages of EBP model by saying that it is too mechanistic, ignores the characteristic of both clients and practitioners and is hard to implement due lack of time and may be outdated when printed. Killen and Barnfather,(2005) disagree with Rubin by stating EBP does consider patients’ preferences and practitioners’ influences in DM. A study carried out by them suggested that using EBP improves patients’ outcomes when compared with those using non EBP nursing care. Additionally, they added the EBP has positioned the nurse to be a significant influence on health care decisions and improving the quality of care.
Allen & Rixson (2008), systematic research was an example of EBP, to review of the impact of Integrate Care Pathways (ICPs) on providing an ‘integrated service’ for patients. The review focused on the care of adult patients who had suffered a stroke and included acute care, rehabilitation and long-term support in hospital and community settings. ICPs were the intervention of interest and ‘service integration’ was the outcome. They critically appraised seven papers, representing five studies. In conclusion the ICPs can be effective, in ensuring that patients receive relevant clinical assessments and interventions in a timely manner and in improving the documentation of rehabilitation goals. Evans (2003), proposes that nurses should use evidence derived from research to make a decision such as expert opinion according to quality criteria, randomised control trials and patient experience. Also it is important for nurses to understand why certain things are done not simply how to do it, for example giving drugs using via syringe driver, nurses should ask “why, when and how” which would help them to understand the importance of the process of action.
A example of a method for EBP is a pain assessment tool for which guidance was developed by The British Pain Society has worked with the British Geriatrics Society and the Royal College of Physicians (2007), to review the current evidence guidance to help nurses and all practitioners to use pain assessment tools to assess for the presence of pain. The guidance helps nurses to be aware of the pain in patients, enquires about the pain by using a range of descriptive such as is it sore, hurting or aching will enable the nurse to reach decision. Furthermore, it helps nurse to locate the pain by asking the patient to point the area themselves to indentify the pain intensity and to identify the cause of the pain and how to treat and to re-evaluate the outcomes.
Pain assessment tool helps nurses to determine the cause and provide best pain management and treatment for the patient. In order for the nurse to assess pain comprehensively, the nurse needs to address the type of pain, detailed history and assessment of the pain intensity. This will helps the nurse to select a pain assessment tools based on the patient’s age, physical, emotional, cognitive status and preference (Kaasalainen and Crook, 2003). Verbal Rating Scale (VRS) is one of the pain assessment tool use to assess pain in patient. It aim is to mange the pain intensity by asking the patient to match pain to a descriptor words and number. The reasoning of using the VRS is what McCaffery 1968, defines pain should be what the patient says it is because a nurse can not measure a patient pain intensity unless the patient said so (Baillie, 2005, p 485). According to Krohn (2002), the nurse uses the VRS scale to ask the patients to describe their pain whether they have on pain, mild pain, moderate pain, sever or worst pain. Once the pain intensity is assessed according to Wells et al (2008), the nurse has to make a decision on which analgesic management and intervention to use in order to achieve optimal comfort and function with minimal side effect from analgesic therapy.
The World Health Organisation (WHO) (1986), suggest that nurses decision should be based on the analgesic administration ladder. Where simple analgesic such as paracetemol should be used for mild pain, weak opioids for moderate pain if not contraindication to renal dysfunction (Ballantye et 2002). A sever or worst pain should be review and a strong opioids analgesic such as morphine should be administer to improve the comfort of the patient. The nurse should monitor and be caution about the safety of the patient because first time analgesia patient will be susceptible to adverse effects such sedation and respiratory depression (National Patient Safety Agency 2008).
Time management is a factor that hinder the use of pain assessment tool. A randomly studies carried out by Manias et al (2005). The study finds out that interruption such as answering the telephone, participating in doctors’ rounds effect pain assessment and possible delay the management of the pain. They added that due to this interruption patient are unable to request pain relief for the fear of being regarded as a nuisance and it have impact on their emotional, physiological and physical function aspect of their lives. Knowledge of pharmacology and analgesic also enhance to decrease anxiety, improve the mood and promote comfort to the patient.
Although using pain assessment tools in adult who speak English and understand the pain score is very effectively are able to give consent about their treatment, but in elderly adult with cognitive impairment will be confuse and not be to able give a reliable measurements of pain intensity, which is likely to result in inappropriate intervention. According to Weiner and Herr (2002), assess pain in patient with impaired communication such as learning disability and mental health patient represent the most significant challenges in pain management and nurses have difficulty knowing when those patient are in pain and when they are experience pain relief. They added that nurse have to depend on their facilitators to describe the pain in which the nurse have to query the reliability during decision. Pain assessment tools used in children is complex for example babies who are unable to communicate, decision and consent has relays on their parent. So during decision making about interventions, the nurse have to use ethical principles of beneficence and non-maleficence to select best pain assessment to provide pain comfort for all the patient (Nursing and Midwifery Council (NMC) (2004).
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According to Wood (2001), nurses in the health care sectors encounter multiple challenges when providing quality care to diverse patient population. This creates ethical dilemmas resulting form the combination of increasing of patients acuity and limited of resources. She added that professional code of practice as a method will enable nurses to make an ethical decision to provide a patient centred care. in order to avoid inconsistency.
Ethical decision making as explain by Ian et al (2006), is when a nurse carefully rational the available evidence by asking a question such as what is the context of the dilemma or the data. identifying the ethical components such as what is the underlying problem or issues. Consider the relevant moral principles such as what alternatives exist and the purpose of each alternative, the consequences of our actions such as what are the social and legal constraints. However they also added, understanding of ethics and law is therefore important in order to guide DM and helps nurse to uphold patients right and protect vulnerable form harm. Also acting accordance with legal and professional code of practice can helps protect accountable nurses from legal action.
The NMC code (2008), recommend that all nurses have the responsibility to work in partnership with patients, their families, carers and organisation. The professional code of practice as a method will provides guidance on how nurse would resolve clinical dilemma during DM. Mooi (2011), stated that, the professional code of practice is an evidence research ethics principles derived from moral philosophy to capture the essential virtues, rights and duties and outcomes , in order for nurses to achieve a patient centred care. He also added that the code of practice consists of four principles which are autonomy which respecting patients’ rights, non-malefiecence not to harm patients, beneficence, promoting the well-being of the patients and justice, treating patient fairly. Ian et al (2006), states that the professional code aids nurses in DM, first of all the nurse assess the background condition affecting the patient life in question and the immediate cause that demand decision, what are the alternative options available and what are likely outcomes will be. The nurses have to consider the relevant rules and moral principles relating to one’s personal and professional duties.
For example a 45 year old woman make an informed refusal about life-preserving treatment against the advice of her clinical team and her family opinion that resuscitation would be a benefit and ought to be undertaken. Although a nurse wish is to achieve good of life preserving and avoid harm of death, Beauchamp and Childress (2001), suggested that in this case, when making a decision the nurse should analysed the 45 year old woman rights, assess her capability of decision and if competent her rights of autonomy should be respect and honoured according to the professional code of ethics practices. According to Snelling (2010), non-maleficence requires that the nurse and other health care professional should not harm the patient. They suggest that during DM, the nurse should research and examine past experience of the success or failure of alternative courses of action when dealing with similar problems. This will helps the nurse to recognise treatment that would be considered beneficial for this patient. Also the nurse need to promote the well-being of the patient. Beneficence helps the nurse to assess the patient circumstances throughout the process of changing moral demand in the patient health situation (Ref). It also helps the nurse to decide where the best interest of the patient lies, and if the nurse overrides that patient wishes for example giving surgical treatment, this is done not out of spite but in the belief of acting in beneficence way. During DM, the nurse applied justice, although the patient refuse life-preserving treatment, she should be treating fairly by assuring that an appropriate standard of care is maintained. In order not to violate the ethical rights of the patient.
Baron (2000), state that lack of knowledge leads nurses to make justified by biased reasons. Since knowledge requires reasoning and calculating the problem from the outside. In a course of resolving dilemma will leads the nurse to imagined sequences of event, the nurse will then make inadequate decision for unknown unexpected reasons. Furthermore he stated that this will prone the nurse to be inadequate when selected ethical decision and this will affect the outcomes and also the standard care delivered or cause harm to the patient. He also suggest that lack of self confidence influence DM in non-rational ways because since nurses are motivated to minimise conflict Capacity can be reduce in many ways such as illness, mental health, learning disability and childhood .
Ethical DM across nursing fields has issues relating to the ability to understand information and consent given. It also raising issues relating to their capacity. Under the Mental Capacity Act (2005), the patient must be presumed to have capacity unless there is evidence otherwise. Autonomy is the sense of having a capacity of making a decision, learning disability or a child may lack the capacity to make decision and to give consent about their medical treatment. This may delay treatment, legally the medical team include the nurse should decide in the best interest of the patient’s as suggested by Cornock, (2002), and their relatives views should not dismissed. Mental health patient’s ability to understand and give consent also depend on their capacity of competent. This is difficult where there is some doubt whether the patient can or not make a decision. Sometimes an adult patient may refuse treatment () of clinical The nurses should assess if the patient has sufficient capacity to give consent then it should be honoured in. Adult with sound mental capacity can refuse treatment despite clinical inte
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