Enhanced Assessment Skills and Decision Making in Adult Nursing

This assignment will highlight an event from clinical practice where it was essential to make a collaborative care decision and will analyse the decision-making process. A collaborative care decision is where there are joint decisions made between more than one person by working together to achieve an agreed care plan or treatment (Standing, 2017 a). Throughout this assignment you as the reader will understand the process of decision making and the related models. Team working, leadership and leadership styles and the ethical issue autonomy will be considered and identified within the chosen scenario.In accordance with the guidance from the Nursing Midwifery Council [NMC] (2015 a), confidentiality will be maintained, therefore any names of people and places have been changed. 

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The scenario from practice is an 82-year-old man called Alan, he was admitted to an elderly medical ward due to a fall. The fall happened at home, with no loss of consciousness, and no head injuries. An ambulance was called because Annette was not able to get Alan up, off the floor. The Paramedics thought it best to have Alan checked over at the hospital. Alan has been well supported at home by his wife Anne. Anne supports Alan with all his care needs at home and is happy in doing so however, she has come in looking tired and expressing she is struggling with the progression of his dementia and anger. Up till now there has been no previous care packages or support at home, other than Annette. Alan has a medical history of bilateral hearing loss, Parkinson’s disease and Lewy body dementia [LBD] secondary to the Parkinson’s. Parkinson’s disease is a progressive neurological disorder which affects the brain and the loss of dopamine cells. These cells that are affected release chemicals to send signals to other nerve cells. Those who have Parkinson’s suffer with tremors, stiffness, impaired balance and co-ordination which can affect mobility, (National Institute of Neurological Disorders and Stroke, 2018). Lewy body dementia [LBD] is a progressive dementia, that involves tiny deposits appearing in nerve cells in the brain, they lower levels of other important chemicals involved in carrying messages between nerve cells, and the loss of connection makes the cells die. The dementia affects movement and changes mental abilities, (Alzheimer’s Society, 2018 a). Current treatment is intravenous fluids due to hypotension and physio assessing and supporting mobility. The collaborative care decision that will be analysed throughout this assignment is whether to support Anne at home with her husband or refer to a nursing home. This decision needs to be made due to his care needs, mental capacity and Anne needing support to care for her husband.

The Mental Capacity Act Code of Practice (2005) refers to capacity as someone who is unable to make decisions or actions for themselves at the time of the decision or when action needs to be taken. Alan lacks capacity because he is unable to understand information specific to the decision, retain the information, weigh up the information available or communicate the decision, (Alzheimer’s Society, 2018 b). All healthcare professionals should assess Alan with his best interests in mind, so it is important to include and encourage him to contribute to decisions and consider his past and present wishes and beliefs, (Social Care Institute for Excellence [SCIE] 2015 a). The best interest’s principles are defined in the Mental Capacity Act [MCA] (2005 a), the act has regulations that are required when any action or decision is made on behalf of someone who lacks capacity.

The collaborative care decision that was being discussed was; should Alan return home with support in place or should there be a referral to a nursing home. This collaborative care decision took place in a discharge planning meeting. Pellet (2016) states the purpose of a discharge planning meeting is to reduce the length of stay in hospital and to prevent further unplanned hospital admissions. Discharge planning is a process that facilitates the transition of care and should begin on admission, (Noseworthy, Sevigny, Laziner, Houle and Riccia, 2014). The discharge planning meeting was arranged by the nursing staff on the ward and involved a multi-disciplinary team and the patients family; consultant, nurse, occupational and physio therapist, district nurse, discharge co-ordinator, Alan and Annette. Collaboration of the different professionals is important because it allows them all to communicate and share views, share responsibility and problem solve to make decisions to carry out care, (O’Daniel and Rosenstein 2008 a). The SCIE (2010) agrees, collaboration is important because it improves transparency of decision making and organisational structure. A collaborative decision is made up of three parts; consultation to communicate concerns, negotiation to agree and identify a plan and co-operation to work together to achieve the shared solution, (Standing 2017 b).  This discharge planning meeting was held in a room on the ward, for privacy. Discharge planning is known as shared decision making because it involves the clinicians and the family. The process provides the person with dementia and their family opportunities to be involved and express their preferences about decisions, (Miller, Whitlatch and Lyons 2014). 

Shared decision making is a three-step process; choice talk, option talk and decision talk. The model rests on supporting and understanding a process of deliberation and respecting what matters most to the patient, which in turn will allow them to make informed preferences, (Elwyn et al 2012). Similarly, Legare et al (2011) and Groen van de Ven et al (2017 a) suggests the decision consists of clinicians, patients and families communicating the decisions and considering the implications, therefore including the person with dementia and any informal carers. Within the meeting it was important to respect what Alan wanted, which was to go home. Annette was unsure of the support she would get looking after Alan but is worried about him going to a care home, due to visiting and being apart. Annette is happy to continue supporting Alan at home with support, the nurses on the ward support her decision, however the consultant wants Annette to explore her options before making a choice. The consultant explored the option of a nursing home due to Alan’s capacity and anger and expressed a nursing home would be able to meet his nursing needs. This is where the process of deliberation started to happen, the consultant wanted the option explored, as Alan’s needs could be met, however, this was not respecting what mattered most to Alan and his family. The consultant was not behaving as a collaborative team decision-maker because he was not working together to co-operate and achieve a shared solution, suggested by Standing (2017 c). O’Daniel and Rosenstein (2008 b) concur, collaboration is working together, problem solving and making decisions to carry out a shared plan.However, it could be argued that the consultant was exploring other options, so Annette had all the information to enable her to make an informed choice for Alan’s care needs, which is the basis of shared decision making. Shared decision making is enabling a collaborative care decision to be made by discussing the health care options and facilitating the patient and family to express their views and develop informed preferences, (Groen van de Ven et al 2017 b). To enable an informed preference, all options need to be explored so Alan and Annette have all the information.

The nurses on the ward supported Annette and agreed that a package of care at home would be beneficial. The nurses worked together to provide a detailed report of Alan’s care needs to be able to assess funding criteria for carers and equipment. After this, the consultant was happy to continue the discharge planning process for Alan to be supported at home. The consultant is showing good characteristics of collaborative working because he was able to combine and balance negotiation, co-operation and adjust his outlook when presented with evidence, (Standing 2007 d).

However, it could be argued that a different decision-making model was used, clinical decision making. Clinical decision making uses clinical judgement to select the best possible and evidence-based option to ensure the best quality care, (Tiffen, Corbridge and Slimmer, 2014). It is evident the nurses used their intuition and experience to assess Alan, by working together to produce a report of information on Alan’s care needs. Stokes (2009) agrees clinical decision making is a process of gathering information and analysing assessment information, so the team can collaborate with the patient and their family. The nurses provided the reports through clinical judgement and everyone involved was able to come to an agreed decision.

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Democratic leadership was used, this is also known as participative or shared leadership. Lewin (1993 a); Frandsen (2014); and Cherry (2018) suggests democratic leadership allows everyone to participate in decision making, but the democratic leader is there to guide and control. The leader encourages communication and staff participation in decisions. During the discharge planning meeting and working together to decide whether Alan goes home, the consultant actively listened to other members of the team. He respected their participation and looked at the evidence they provided about Alan’s care and he made the final decision. There are various team members involved in Alan’s discharge planning, a democratic leadership allows for the decision to be shared and values each member contribution. Democratic leadership can work well within multi-disciplinary teams, e.g. discharge planning allowing the shared decision model to be used. Lewin (1993 b) found democratic leadership enhanced inclusion and decision making through sharing ideas and collaborating as a team. However, Goleman, Boyatzis and McKee (2002) argues a big disadvantage from democratic leadership is the loss of speed in decision-making because it requires everyone’s input therefore making decisions timely as meetings need to be arranged and discussions had. Therefore, democratic leadership could enhance shared decision making as it allows collaborative working.

However, Bass and Riggio (2008) suggest transformational leadership could have worked well because it has ability to inspire and motivate others to act. This type of leadership focuses on building relationships and encouraging one another which builds moral and motivation. Within the multidisciplinary team it was important to ensure everyone was motivated to deliver the care Alan needed. It was also important to build a relationship with both Annette and Alan, so decisions could be made. Transformational leadership is considered the most influential theory as it’s the highest one considered in studies, (West et al 2015). Cummings et al (2008); McFadden, Henagan and Gowen (2009); Apekey et al (2011); and Wong, Cummings and Ducharme (2013) found evidence that transformational leadership has positive outcomes to nursing care, patient safety and patient satisfaction. 

Under the NMC (2015 b) there are ethical principles that nurses must follow, the principles promote patient choice and to do no harm. Beauchamp and Childress (2001 a) standardised framework in which to analyse ethical situations. The four principles are; Autonomy, the right to make your own choice and that choice be respected whilst enabling informed choices, Beneficence, acting in the best interest of someone, Non-maleficence, to do no harm and Justice, fairness and equality. Alan’s autonomy is important, (Beauchamp and Childress 2001 b) suggests Alan’s choice of going home should be considered and respected, even if the decision is not the ‘correct’ decision. An autonomous decision should be one that is informed. Mulley, Trimble and Elwyn (2012) suggest, patients who are well informed of options and decision can better articulate their preferences.  Although Alan lacks capacity because of his dementia, it should be assumed all adults are able to make their own decisions, to have capacity information should be understood, processed, retained and information should be weighed up, (MCA, 2005 b). The SCIE, (2015 b) suggests a person can lack capacity on big decisions but still have capacity to make small ones. Therefore, Alan can make decisions and voice that he would like to go home because the Human Rights act (1998); the MCA, (2005 c), and the ethical principle of autonomy underpin the multi-disciplinary team’s actions. Alan should be included in decision making, Department of Health [DH] (2012) “no decision about me, without me” gives patients more opportunities to make informed choices. Alan was included in the discharge planning meeting and was asked at different times of the day where he would like to go to ensure that he had opportunities to express his opinions. Alan’s choice of going home was respected and taken into consideration by the multi-disciplinary team. The option was explored and identified as a safe option, therefore causing no harm. Whilst respecting Alan’s autonomy, his lack of capacity enables Annette and the multi-disciplinary team to respect his beneficence. To do so, the decisions should be least restrictive to Alan’s rights and freedom, enhancing fairness. The team worked well and respected Alan’s ethical principles whilst working alongside Annette to provide information that allowed Annette to act in Alan’s best interest with informed choices.

However, at first the consultant was pressing for a nursing home to be the place of discharge. The consultant was not supporting Alan or taking his preferences into consideration. At this time the consultant was not working ethically as the emphasis should have been on respecting the persons with dementia autonomy and involving the person in decision-making, (Nuffield Council on Bioethics 2009). The consultant needed to approach the decision-making process through person-centred care. Thornton (2011), person-centred care looks at care ethically and values the person and not their cognitive status. Perhaps the consultant was looking at the decision through Alan’s cognitive status rather than basing decisions holistically.

In conclusion, decision-making is required in health care, all professionals need to in different environments and with complex health needs.Shared decision making, and clinical judgment were used in the scenario and they worked well with Alan and his complex health needs. Evidence suggests that combining shared decision making and clinical judgement enhanced the quality care, Alan’s autonomy and the multi-disciplinary team were able to agree on a suitable outcome that benefited Alan. Graham, James and Spertus (2018) agree, decision support models provide and facilitate clinical decision making which delivers personalised care. Overall the team worked well, with the consultant adopting a democratic leadership, although evidence suggests a transformational leadership would have worked also.

Through learning about the decision-making models and identifying them when they are used and how it is relevant to clinical decisions, future practice can be adapted to use different models to engage patient participation and enhance quality care. Education studies alongside clinical judgment for student nurses help them to engage with patients, understand moral reasoning and enhance quality care, (Tanner, 2006). This enhances future practice as a nurse as these specific skills are attained, understood and reflected upon whilst recognising any failures.

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