Clinical Decision Making in Nursing - Case Study Example

CLINICAL DECISION MAKING IN NURSING Introduction: Recent policy changes and trends in professional development in the health care system have entrusted nurses with greater responsibilities in patient care. The decisions they make have a significant impact on health care outcomes and patients’ experiences (U.K. Dept. of Health: 2006)1. Although judgement and decision making are closely linked, they generate separate cognitive demands, as they are distinct from each other, according to Dowding; Thompson (2003: p.49). Judgement can be defined as an “assessment between alternatives”, and decisions have been defined as a “choice between alternatives”(Dowie, 1993 cited in Dowding; Thompson, 2003: p.50). High quality judgements and decisions consist of the current situation being assessed accurately, and appropriate action taken on the basis of that assessment. Reflective practice informs decision making: learning to make decisions on the basis of knowledge and experience results in evidence-based practice, states Jasper (2006: p.5). Clinical judgement, critical thinking, diagnostic reasoning and clinical decision making are all closely related in their cognitive aspects and functions. Clinical Judgement is defined as the ways in which nurses come to understand the problems, issues or concerns of clients or patients, to attend to salient information and to respond in concerned and involved ways (Benner et al, 1996: p.2) as cited in Rashotte ; Carnevale, 2004: p.162. Cited in the same article by Rashotte: Carnevale is Facione, et al, 1994: p.345, who defines Critical Thinking as a process of purposeful, self-regulatory judgement: an interactive, reflective, reasoning process; and Lipman and Deatrick, 1997:p.47, who defined critical thinking as: the careful, deliberate, goal-directed thinking, based on principles of science and the scientific method. Cited in the same article by Rashotte; Carnevale, is the definition of Diagnostic Reasoning by Carnivali, 1984: p.26: A complex process of observation, critical thinking and data gathering process, used to identify and classify phenomena that are encountered in presenting clinical decisions. Matteson and Hawkins, 1990: p.121 are similarly cited by Rashotte; Carnevale (2004: p.162). They state that Decision Making is the process of making a mental choice between two or more options that follows a consideration of all the variations of the options. The term Clinical Decision Making can be used with the understanding that all the terms defined above describe a single entity. The value of the decision that is made depends on the validity and accuracy of the details of a case and the comprehensive information available according to Hancock; Durham (2006: p.1). The quality of decision making becomes imperative with the roles of nursing extending into what was previously the domain of medicine, and increased demand for evidence-based practice. Discussion: THE IMPORTANCE OF DECISION MAKING IN NURSING PRACTICE: The essence of good care delivery is problem solving (Taylor, 1997: p.329). The commonly used methods for problem solving are: trial and error, intuition, experimentation and the scientific method. The first three methods stated cannot be considered as reliable. Trial and error and experimentation methods for problem solving can be considered only in the case of new symptoms or disease epidemiology about which previous knowledge is not present. Intuition is a concept which plays a significant part in specific cases, and is taken into account when dealing with serious and uncertain conditions. In the scientific method of problem solving, academic knowledge about the case will be the basis of forming judgement, and in deciding treatment options. Behaviours based on critical thinking are essential to a nurse’s role as clinician, manager, researcher or teacher (Swansburg, 2002: p.1). Problem solving by taking the right decisions is crucial to patient care. Hardin; Kaplow (2004: p.57) state that clinical judgement is at the heart of nursing. Clinical judgement is a competency which has historically been grounded in the nursing process of assessment, planning, intervention and evaluation. Expert nurses relied on experience, intuition, practical intelligence, and academic knowledge (Benner, 2001; Benner et al 1996, as quoted in Hardin; Kaplow 2004: p.57). Since critical thinking is a part of the nursing process, it is considered to be a logical and rational way for nurses to organize and manage care. Nurses are both responsible and accountable for making the right decisions at the right moments in time to ensure optimal patient and family outcomes, and safe passage through the healthcare system. Reflection and critical thinking are used, for making the best decision for the patient given the context of the situation (Hardin; Kaplow 2004: p.57). Thompson; Dowding (2002: p.2) reiterate that healthcare professionals have to deal with uncertainty in their decision making. Key policy makers have developed an evidence-based culture in healthcare, with a focus on the quality of decisions taken by healthcare professionals. Judgement and decision making are intricately linked, and intuition and expertise are also important factors in good decision making. Albarran, et al (2006: p.6) link experiential wisdom and excellence with expertise, which requires active teaching and learning. Expertise has to be sustained with new knowledge and experience, supported with critical scrutiny and constructive, reflective analysis, to keep the condition evolving and growing. Medical decision making, according to Rashotte; Carnivale (2004: p.164) is a sequential cognitive activity, in which early problem identification and hypothesis generation guide subsequent data collection and hypothesis evaluation. Numerous nursing studies examining decision making using this hypothetico-deductive model, have concluded that nurses make judgements about patient care in a rational process. Although different numbers of phases have been suggested by various researchers, common features in the decision making series of steps are: a) Gathering preliminary information and organizing cues into patterns. b) Generating tentative hypotheses. c) Interpreting the cues and confirming or refuting the hypotheses. d) Making the judgement based on weighing the pros and cons of each possible explanation and choosing the one favoured by the majority of the evidence. Research Into Clinical Decisions: Beck, et al (2004: p.3) state that to accomplish diverse and sometimes conflicting goals, nurses must access and evaluate extensive clinical information and incorporate it into their clinical decision making. Nurses are increasingly expected to become producers of new knowledge through nursing research. Research is systematic inquiry that uses disciplined methods to answer questions or solve problems. The ultimate goal of research is to develop, refine and expand a body of knowledge. Nursing research is systematic inquiry designed to develop knowledge about issues of importance to the nursing profession, including nursing practice, education, administration and informatics. Clinical nursing research generates knowledge to guide nursing practice and to improve the health and quality of life of nurses’ clients. This is done by incorporating research-based knowledge into nursing practice. The Accessiblity of Research-Based Knowledge for Nurses in United Kingdom Acute Care Settings: The development of evidence based approaches to health care, according to Thompson, et al (2001: pp.11-12) rely on the clinicians having access to the best available evidence; evidence fit for reducing the uncertainties associated with clinical decisions. Three perspectives on accessibility were identified: 1) The humanist: in which human sources of information were the most accessible. 2) Local information for local needs: in which locally produced resources were seen as the most accessible. 3) Moving towards technology: in which information technology begins to be seen as accessible. Nurses’ perception that human sources are more accessible than text-based sources, called for a strategy for the increased use of research evidence by nurses. Harnessing the influence of clinical nurse specialists, link nurses, experienced clinical colleagues, and those engaged in practice development, would be useful. These roles could act as ‘conduits’ through which research based messages for practice, and information for clinical decision-making could flow. This role should be explored and enhanced (p.12). DECISION MAKING MODELS: UNDERLYING CONCEPTS: Azuma, et al, (2005: p.1) state that while there are many different models of decision making, there are underlying cognitive processes and issues that are common to most decision making models. From a general cognitive perspective, decision making is the process of selecting a choice or course of action from a set of alternatives. Most models describe the human process of decision making as serial staged processes that include steps centred on information gathering, likelihood estimation, deliberation, and decision selection. Related fields of psychology include inductive and deductive reasoning, rational choice theory, decision analysis, game theory; as well as more general theories of foundations of probability, utility theory and logic. These theories and processes are useful because they attempt to describe how humans execute particular stages of decision making. The two fundamental processes that underlie human reasoning and decision making are attention and memory. Attention is how the brain often consciously though sometimes automatically selects information for cognitive processing. Human memory is the capacity to encode, store and retrieve information. A variety of different reasoning techniques exist, one of which is analogical reasoning: inferring novel solutions via analogy to known solutions or methods (pp.1-2). FRANZ PORZSOLT’S DECISION MAKING MODEL: Porzsolt, et al, (2003: p.165) state that: Health related decisions based on a synthesis of internal and external evidence form the basic concept of evidence-based medicine. Internal Evidence is composed of knowledge acquired through formal education and training, general experience accumulated from daily practice, and specific experience gained from an individual clinician-patient relationship. External Evidence is accessible information from research. It is the explicit use of valid external evidence (eg. randomised controlled trials) combined with the prevailing internal evidence that defines a clinical decision as “evidence-based”. The initial five-step approach to evidence-based medicine teaching programme was not readily used by students. The researchers: Porzsolt et al are of the opinion that throughout medical education, students are virtually “trained” to make decisions under the condition of uncertainty. Advanced students and to a greater extent clinicians lose some of their ability to differentiate between scientific evidence, and what appears to be evident. For the purpose of higher efficiency in implementing evidence based medicine, modification in the way students and clinicians learn to make decisions, is required. To make the strategy a usable one, an additional step (Step No.2) was introduced in the evidence based approach to decision making. Students were to provide answers to their clinical questions, based on their current knowledge (internal evidence), before continuing with the remaining steps of the evidence-based process. The inclusion of the additional step resulted in positive response from students. They were satisfied that their pre-existing knowledge had been integrated into the evidence- based approach (Porzsolt et al, 2003: p.165). Franz Porzsolt et al’s Model: The Six Steps of Evidence Based Decision Making Step Action Explanation. 1. Transformation of the clinical problem (a) Relevant patient characteristics and into 3 or 4 part question. problems. (b) Leading intervention. (c) Alternative intervention (d) Clinical outcomes or goals. 2. Additional step: answer to the question Internal evidence: acquired knowledge based on “internal evidence” only. through professional training and experience (in general and applied to the patient). Should be documented before proceeding to Step 3. 3. Finding “external evidence” to answer External evidence: obtained from the question. Textbooks, journals, databases, experts. The value of the external variable will be highly variable, see step 4. 4. Critical appraisal of the external evidence. Should answer 3 questions: (1) Are the results valid? (2) Are the results clinically important? (3) Do the results apply to my patient? (or is my patient so different from those in the study that the results do not apply?) 5. Integrating external and internal evidence. The two sources of evidence: external and internal, may be supportive, non- supportive or conflicting. How the decision is made when non-supportive or conflicting will depend on multiple factors. 6. Evaluation of decision making process. Once the decision has been made, the process and the outcome are considered, and opportunities for improvement are identified. By explicity documenting their internal evidence, students used the remaining steps of the process to evaluate not only the best evidence in making a clinical decision, but also to assess the accuracy of their internal evidence, the grounds upon which their preconceptions were based, and the usefulness of the available literature, in supporting a decision for their patient. The comprehensiveness and validity of Franz Porzsolt’s model of the six steps in decision making, is the reason for the model’s selection as the framework for decision making in the Patient Scenario to be discussed. Discussion and Analysis of Franz Porzsolt, et al’s Model of the Six Step Approach to Evidence Based Decision Making: Porzsolt et al (2003: p.166) state that agreement between internal and external evidence varies. Completing the full process could result in finding evidence that confirms the internal evidence, validating and strengthening the clinician’s or student’s confidence in the decision. The process could also reveal that little evidence exists to support the decision, or that the available evidence is equivocal. In such cases, other factors such as cost or inconvenience to the patient may need to be given greater consideration. Possibly, the best external evidence found is not in agreement with the internal evidence. This represents a particularly valuable experience for the clinician or student because it may avoid an ill-advised decision. It also shows the fallibility of making decisions on uncertain grounds based on internal evidence alone. This in turn will hopefully promote the routine assimilation of external evidence in clinical decision making. The documentation and comparison of steps 2 and 5, used as a research tool or quality assurance outcome measure, could provide valid information on the effects of evidence based medicine on clinical decision making In case of conflicting internal and external evidence, clinicians have several options. They may change their mind and align it with the external evidence. They may determine that the external evidence is not sufficiently convincing, and remain with the original decision. Or, they may choose to discuss with the patient the conflict between the internal and external evidence in a manner that enables the patient to take part in the decision making process. This last approach is recommended because patient preference is considered an essential part of the evidence based decision making process, and decisions often need to be made in the absence of clear research findings (Porzsolt, et al, 2003: p.166). PATIENT SCENARIO: The patient is a seventy-eight-year old lady named Mrs. Guy. She was admitted to the ward for respite care. She is non-mobile, and has a known history of long term incontinence. When nursing staff were bed-bathing Mrs.Guy, we noticed that her sacral area was very sore and excoriated. She was wearing incontinence pads. Since I have been assigned the responsibility of caring for her, decisions regarding management and treatment for her sacral area to heal, have to be taken. An intervention that is under my consideration is catheterization, so that the use of incontinence pads can be avoided, and the sacral area will be able to heal. Franz Porzsolt, et al’s recognized evidence based decision making model will be used as a framework, for making the decision in Mrs. Guy’s case. Identification of Decision to be Made: Study of the various options for treatment of Mrs.Guy’s bedsores in the sacral area, and consideration of catheterization as the intervention to help in healing of the excoriated skin. Urinary Incontinence: According to Cardozo et al (2000: p.19), Incontinence is defined by the International Continence Society as a condition in which there is involuntary leakage of urine, which is objectively demonstrable, and is a social or hygienic problem. Urinary incontinence generally occurs if the pressure in the bladder unintentionally exceeds that within the urethra during the filling phase of the micturition cycle. The various types of incontinence are: stress incontinence, urge incontinence, mixed incontinence in which both the above symptoms are present, night-time incontinence and dribble incontinence. This is a common problem at all ages, but is most prevalent in the elderly, especially among those living in an institution. According to the Continence Foundation, 25% of women and nearly 10% of men will suffer from incontinence at some stage in their lives. A gallup poll conducted in 1994 showed that a majority of sufferers put up with their symptoms and failed to seek medical help. Most of those who do seek help, do so after several years of enduring the symptoms and unhappiness this condition causes (p.1). In the United Kingdom, Primary Care Groups have the responsibility for buying continence promotion, education and support services from community trusts and voluntary agencies. They are also responsible for establishing contracts to ensure that adequate supply networks exist for continence projects(p.1). Incontinence is stated to be an extremely expensive problem for consumers as well as the health care industry. It also contributes to environmental pollution. The hygiene pads used are not recyclable, and they create additional burden for an already overburdened waste disposal system. Health care economists along with the medical research community are exploring ways to cure, prevent, or reduce the number of people who have conditions such as incontinence related to the aging process (Newman; Dzurinko, 1997: pp.1-2). Until recently, state Newman; Dzurinko (1997: p.106), most health care professionals viewed incontinence as an inevitable part of aging, and managing incontinence meant putting the patient in a diaper or using a catheter. Today there is a growing understanding among physicians, nurses and other providers that there are several treatment options open to men and women with urinary incontinence. The consumer has to seek help or find a resource person at the earliest, because the problem worsens with age. Coping Strategies in Urinary Incontinence: Cardozo (2000: p.65) state that these include advice on fluid intake, diet, good bowel habit, and altering voiding routines. Fluids: Fluid restriction may prove to be counter-productive, since the bladder becomes more sensitive to lower volumes as it is seldom stretched to full capacity. Restricting fluid intake also increases the tendency to constipation. Fluid consumption should be moderate, about 1 to 11/2 litres in 24 hours. Caffeine: Caffeine has a marked effect on bladder function because it is a xanthine derivative, occurring naturally in tea and coffee, and has a similar effect to a thiazide diuretic. It also causes detrusor muscle overactivity. Diet: Patients with detrusor instability must take special care with their diet. Certain foods such as citrus fruits and tomatoes can make their condition worse, particularly in patients with interstitial cystitis. Such patients are advised non-acidic fruits. Cranberry juice is considered to be beneficial because it reduces bacterial infection in the urinary system. Consitpation should be avoided by any patient with urinary incontinence. Body weight: Since a significant relationship exists between body mass index and all types of urinary incontinence, obesity should be avoided (p.66). Economics in Nursing Management: Cardozo et al (2000: p.1) state that the costs of continence care are hard to calculate accurately because incontinence is grossly under-reported by sufferers and undiagnosed by primary health care teams. In the United Kingdom, incontinence costs the National Health Service an estimated 70 million pounds a year, in pads and aids alone. The cost to the individual in terms of impaired quality of life, and the cost to the National Health Service of diagnosis and treatment have to be taken into consideration. This common and costly problem is eminently treatable in the community setting. Despite an initial increase in costs resulting from improvements in diagnosis, there should be a long-term decrease in the national cost of incontinence with measures such as education and training for improved management of urinary incontinence in primary care. According to Mannion, et al, 2005 there has been a drive on the part of government and from within the nursing profession, to enhance the science base and promote cost-effective health-care interventions. This has generated new interest in the ‘economics of nursing’ as efficiency and ‘value for money’ are viewed as necessary precondition for the provision of a high quality nursing service. A range of alternative economic approaches have been developed which challenge many mainstream health economics assumptions. The assumptions of dominant economic models should be questioned, and a range of economic frameworks should be explored, when planning services and evaluating their practice (p.377). According to Laycock; Haslam (2002: p.241), Audit is a systematic process that checks and reviews. Audit examines and evaluates: 1) The available resources to provide care, the quality of the resources. 2) The treatments and interventions: the quality of care 3) The outcomes of service provisions and care provided in terms of quality of life. 4) The inputs of care including costs, skills and workload; and the outputs of care that include productivity (case loads, cure rates, value for money, etc) and patient outcomes (clinical response and satisfaction). Treatment Methods: According to Holmdahl, et al (2000: p39), investigations of incontinence include case history and physical examination. A thorough case history regarding neurological diseases, lesions or symptoms is important. The various treatment methods are(pp.85-164): administering medicines, physiotherapy, hormone treatment, bladder training, electrostimulation and surgical treatment. The choice of treatment method depends on the cause of incontinence. Complementary treatment methods are: osteopathy, acupuncture, reflex therapy and homeopathy (Laycock; Haslam, 2002: pp.211-234). Technical Aids: (Holmdahl, 2000: p.165) state that technical aids are used to stop or alleviate incontinence temporarily or for a longer period of time. The use of tampons, pads and pessaries: rectangular and ring-shaped, serve generally as temporary aids, while the patient is awaiting surgery. Anticholinergic drugs or other medication, depending on the cause of incontinence, with catheterization can be the best treatment option, leading to both continence and complete emptying of the bladder. Accountability: The legal environment affects nurses in many ways, from negligence concerning breaches of the legal duty of care to patients and others, to the nursing profession’s governing body: The Nursing and Midwifery Council (NMC 2004)2 according to (Tingle; McHale 2001: pp.1-2). DECISION MAKING WITH REGARD TO THE CHOSEN PROBLEM, USING FRANZ PORZSOLT, et al’s DECISION MAKING MODEL AS A FRAMEWORK: Using the Six Steps of Porzsolt et al’s Evidence Based Decision Making model as a framework, management of the presented case is to be done. The patient, Mrs. Guy is elderly and non-mobile. She was admitted to the ward for respite care. Step 1: Action: Transformation of the clinical problem into 3 or 4 part question. Explanation: (a) Relevant patient characteristics and problems: Name: Mrs. Guy, Age: 78 years, Sex: Female. Admitted in the Hospital for respite care. History of long-term incontinence. The patient has been wearing incontinence pads. The skin of her sacral area was very sore and excoriated. (b) Leading intervention: Use of a catheter as the leading intervention, to allow her sacral area to be maintained in a dry and clean condition, so that healing can take place. (c) Alternative intervention: 1) Use of oral antibiotics and local application of a soothing antiseptic powder after cleaning the area, to help the infected skin to get healed. 2) Change the position of the patient so that she reclines on her sides a part of the time, allowing the back to remain in contact with air, so that dryness is maintained on the skin. (d) Clinical outcomes or goals: The sacral area should get healed from the soreness and excoriation of the skin. Step 2. Action: Additional step: answer to the question based on “internal evidence” only. Explanation: Internal evidence: The use of hygiene pads continuously as a matter of routine, is harmful for the skin of the diaper area, and can cause serious discomfort with the absorbed urine remaining in contact with the skin. Step 3. Action: Finding “external evidence” to answer the question. Explanation: Incontinence is observed to be a very expensive condition, in terms of the required hygiene pads that have to be regularly used, as well as the lowering in the patient’s quality of life. Also, environmental pollution and waste disposal problems are seen to have increased due to the pads which are not recyclable (Newman; Dzurinko, 1997: pp.1-2). Step 4. Action: Critical appraisal of the external evidence. Explanation: (1) Are the results valid? Answer: The authors Diane Newman and Mary K. Dzurinko have published the results of their study in the book: The Urinary Incontinence Sourcebook, 1997 published by McGraw-Hill Professional. (2) Are the results clinically important? Answer: The results regarding the high costs in terms of expenditure as well as in quality of life, and the environmental pollution caused are more economic and social in nature, and not clinically important. (3) Do the results apply to my patient? Answer: The results do apply to my patient. Step 5. Action: Integrating external and internal evidence. Explanation: In this patient, Mrs. Guy’s case, it is seen that both the internal and external evidence point towards the discontinuation of the use of hygiene pads. Both sources of evidence are supportive of each other. Thus, the first decision to discontinue the use of hygiene pads can be considered to be evidence based. The use of catheter should be only a temporary measure, so that the patient’s sacral area can heal well. The option to be considered as a permanent measure should be surgical or pharmaceutical, taking into consideration the cause of the condition: stress-incontinence, urge-incontinence, mixed-incontinence, night-time incontinence or dribble incontinence; and also the patient’s age and capability to undergo surgery. There are several treatment options now available for incontinence in both men and women, according to Holmdahl, et al (2000: 85-164). They are: administering medicines, physiotherapy, hormone treatment, bladder training, electrostimulation and surgical treatment. Step 6. Action: Evaluation of decision making process. Explanation: The decision to introduce a catheter for evacuation of urine from the bladder has been clearly identified. The technical aid, a catheter would be fitted, so that the patient who is elderly and non-mobile can be free from the hygiene continence pads that she was in the habit of wearing. Her sacral area should be washed and cleaned gently, dried, and an antiseptic powder applied locally on the sore skin. The position of the patient should be changed once in a few hours, and she should be encouraged to recline on her sides, as much as possible. The outcome of the intervention would be that the urine-burnt and excoriated skin of the sacral area will be left unpadded, and exposed to the air for healing. Opportunities for improvement: Incontinence should come out of the closet, and those who suffer from the condition should seek medical help. Health care professionals should be alert to identify patients who are silently suffering from this problem, and should encourage them to get the treatment that they require. Conclusion: Evidence based health care is founded on clinical decisions that are based on the best available scientific research evidence. It is premised on the belief, state Lemieux-Charles; Champagne (2004: p.42), that the use of research evidence leads to better health care decisions which in turn lead to better health outcomes. In this paper, the importance of decision making in nursing practice has been discussed at the outset. Franz Porzsolt and his team’s decision making model was selected, the reasons for selecting the Six Steps Evidence Based Decision Making model were given, and the model was analysed: regarding its pros and cons. The aspect of nursing practice that was selected, which required a decision to be made was: incontinence. In a fictitious patient scenario about a 78-year-old lady, Mrs.Guy, the nursing management of the patient’s problem was studied. A clinical decision was made, using the frame work of the recognized evidence based decision making model of Dr. Franz Porzsolt, et al, 2003. The clinical decision was to install a catheter, discontinue the use of continence pads, clean, dry and medicate the affected sacral skin, and allow it to heal. This intervention was for providing immediate relief to the patient. Further treatment, surgical or another would be planned for long-term cure of the problem. REFERENCES Azuma, Ron; Daily, Mike; Furmanski, Chris. (2005). “A Review of Time Critical Decision Making Models and Human Cognitive Processes. IEEEAC Paper # 1650. Version 3. Albarran, John W; Scholes, Julie; Williams, Caroline. (2006). Developing Expertise in Critical Care Nursing. 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