Assessment and Decision Making in Nursing - Essay Example

?Assessment and Decision Making in Nursing Table of Contents 0.Introduction 3 2.0.Legal Consideration And Ethical and Moral Conflicts In Respiratory Nursing 4 3.0.Various Assessment Tools in Respiratory Nursing 9 4.0. Examination of the Relationship between the Theories of Decision Making In the Provision of Nursing Care Delivery 12 5.0. Determination Of The Effectiveness Of The Clinical Decision Making 17 6.0. Conclusions and Recommendations 20 References 22 1.0. Introduction Respiratory nursing or pulmonary care nursing is an area which can be preferred by nurses to enter into. The nurses choosing respiratory nursing as a career path are supposed to work for the patients suffering from lung conditions. The lung condition, referred here, can include anything such as asthma, tuberculosis and cystic fibrosis. Respiratory nurses perform numerous activities; therefore their education and training are of utmost importance (Degrees Finder, 2011). It can be stated that decision making is one of the chief elements of the nursing work which is quite significant to comprehend since organisations discover cost effective ways for the purpose of delivering quality healthcare (Boblin-Cummings & Et. Al., 1999). Clinical decision making is also termed as clinical reasoning, clinical inference, clinical judgment as well as diagnostic reasoning. However, the authors Hardy & Smith further suggest being careful regarding their interchangeability when others are making use of the same activity. Clinical decision making can be explained as the procedure through which informed judgment can be made regarding the treatment that is necessary for their patients (Hardy & Smith, 2008). 2.0. Legal Consideration And Ethical and Moral Conflicts In Respiratory Nursing A respiratory nurse has to deal with the patients suffering from lung diseases. The respiratory nurses are supposed to effectively work with the patients belonging to all the ages in order to promote good health of the lungs. The patients who are suffering from adverse lung conditions need to be placed on ventilators or served with oxygen machines so that they can be assisted with breathing (Rafferty, n.d.). It is to be mentioned that most of the times the ethical responsibilities of the respiratory nurses conflict with the legal considerations in providing such care services. For instance, the role of the respiratory nurses is quite complementary to that of the respiratory physicians. In the recent times, with the widening of the scope of the respiratory nurses, independent clinical decisions in the provision of care and medical management of the respiratory patients is being made by the respiratory nurses. The main responsibility of the respiratory nurses lies in taking clinical decisions and in performing the requisite technical skills. However, the ultimate responsibility lies with the respiratory physicians (Rafferty, n.d.). For the development of the rules and the regulations regarding the drugs to be prescribed to the patients by the respiratory nurses without the references of the medical doctors, there is not any legal or professional barriers until and unless such rules and regulations meet the legal requirements and is supported by consultant medical staff. In this regard, it can be mentioned that such administration of the drugs for the patients need to have a legal, managerial as well as social support and needs to be accepted practise (Rafferty, n.d.). There are various legal responsibilities that the respiratory nurses are supposed to possess. The respiratory nurses who have obtained registration needs to ensure that their practices and conducts at nursing are according to the standards that has been set and thus meets the legal requirements. It can be stated that the registered respiratory nurses are held responsible for their own action most of the time. They are further responsible for participation in the activities through which the quality could be improved. It is the duty of the registered nurses to evaluate their practices on a continuous basis and thus take the required steps so that the personal competence can be improved (Schwab & Gelfman, 2005). When the healthcare setting is considered, respiratory nursing standards needs to make use of the clinical rules and regulations or guidelines identifying the required results in the patient possessing specific medical conditions along with the care that nurses are supposed to provide for achieving the outcomes. The clinical rules and regulations tend to include the parameters required for nursing care at given specific context. Within the periphery of the institution and the agency, the guidelines of nursing administer the process to be followed by the nurses, establishing the standards for the care and thus identification of the time saving process of recording the care of the patient. It is worthy of stating that the legal inferences of the nursing rules and regulations along with the clinical guidelines are vague. It is used in the respiratory nursing care in the recent items. If there is no rules and regulations related to the nursing then it can be stated that in such cases it becomes evident that there is poor management practices at that particular healthcare setting (Schwab & Gelfman, 2005). The prime reason for the change in the responsibility of the respiratory nurses has been the lessening of the working hours of the junior doctors. In the recent times, nurses tend to play a vital role and thus take part in innovation and therefore the nurses are instilling innumerable skills within them, which was once one of the significant roles of the doctor remit. Physical assessment can be considered as an illustration that does not have much of the evidences in order to prove its use in any kind of context. When examining the proper utilisation of the physical assessment in the respiratory section, it has been noted that even though the peri-arrest symptoms could be recognised earlier, its use demonstrates the legal and training problems (Wheeldon, 2005). It can be mentioned that the respiratory nurses who are providing care to the patients suffering from chronic respiratory problems need to identify whether the treatment that is offered to the patients seems to be beneficial or the treatment needs to be stopped for the time being. The main objective of the medical ethics is to enhance the care that is provided to the patients by means of recognising, evaluating and thus attempting to solve any sort of ethical problems arising in the clinical proactive. It can be stated that two chief ethical theories are utilised for the explanation of the moral issues. These two theories are consequentialism and deontology. Respect for autonomy can be considered as a significant part of the nursing. It requires the nurses to have proper consultation with the patients and thus obtain permission from the concerned authority prior to helping and caring for the patients. It is to be mentioned that the administrations of end-stage respiratory diseases need to be divided. One can achieve better results, if the focus is placed upon the symptom relief, involvement of the patients and the families in the decision-making process and the education related to chronic disease in the patient. It comes within the legal and ethical periphery that the nurses are supposed to inform the patients suffering from the end-stage respiratory diseases regarding the severity of the disease and needs to make them clear regarding whether the treatment will be of value or not. Respiratory nurses also need to inform the patients regarding their treatment at the hospital during the time of their illness and needs to be informed regarding the support that the patients are supposed to receive both emotionally and physically at the hospitals (Nursing Times, 2007). The ethical issues also need to be taken into consideration by the respiratory nurses. It is expected that the nurses conduct their duty with honesty, respect and integrity. Unethical practices at the organisation or any other professional misconduct needs to be reported to the concerned and appropriate person. It is the nurses who are supposed to take care of the patients’ rights towards dignity, respect, access to information, and autonomy. The nurses further need to ensure that her relation with the patient is professional and beneficial (College & Association of Registered Nurses of Alberta, 2005). In the field of nursing, three main components are analysed such as integration of virtue, caring relationship and caring behaviour. Furthermore, the main goal of the nursing practices is good care which is part of the moral practice (Gastmans & Et. Al., 1998). It can be stated that the respiratory nursing is completely based upon the moral code of responsibility. This is further embodied in the concept related to service along with respect for human life. When caring is viewed linguistically, in that case, it can provide certain valuable insights as the responses that tend to be ethical moral behaviour of nurses. Caring can be best practiced when the respiratory nurses demonstrate their ideas related to respect and preserving of the humanity. In case of depersonalising discourse, both the respiratory nurses along with the patients do not participate in mutual interchange thus lessening effective caring. There are two feeling that morality actually requires. The first feeling is related to attitude regarding natural caring and reminiscences of caring and being cared for. The care is influenced by social structure by means of language and environment; therefore care is generally explored by evaluating the language. The impact of other social structures on the caring procedure of the emergency nurses can be identified when they are expressed orally (Feininger, 1990). It has been noted that the respiratory nurses are at times not capable of realising the moral dimensions related to their issues. Furthermore, they are not capable of identifying the ways through which the moral issues can be solved. For instance, when the patients in the respiratory ward needs to be served with injection as per the urgency, the moral and the ethical consideration when taken into account will require the respiratory nurses to immediately serve the patients with the injections. However, as far as legality is concerned the respiratory nurses are supposed to take the approval of consultant physicians prior to doing that. It has further been noted that there are several components such as lack of autonomy as well as authority, insecurity and powerlessness, have an impact upon the perception and attitudes of the nurses in light of the moral issues (Georges & Grypdonck, 2011). 3.0. Various Assessment Tools in Respiratory Nursing It is worthy of mentioning that the government policies related to healthcare along with community care requires sensitive as well as systematic assessments. It is via multi-agency and multi-disciplinary affiliation, one is capable of augmenting the patients care, wastages of the valuable resources can be prevented and thus there is likelihood of receiving positive influence upon the health and social care system (Royal College of Nursing, 2004). It is because of the deterioration in the respiratory status of the patients that leads to critical illness of the patients. It is the duty of the respiratory nurses to have a thorough knowledge on conducting the assessment of the respiratory status of the patient. Such assessments need to be carried out on a regular basis by the respiratory nurses when the patients possessing respiratory problems are admitted to a respiratory ward. Observation is identified as one of the assessment tools that can be used by the respiratory nurses in the respiratory wards. The general appearance of the patients needs to be observed when faced with such respiratory problems. They must observe the skin colour, movement of the chest, posture and work of breathing. The respiratory effort of the patient is what is understood by work of breathing. The patients having high work of breathing indicates that the patients are facing problems in breathing (Kennedy, 2007). The use of the questionnaire is quite effective in respiratory wards in order to identify the severity of the illness of the patients. It has been noted that most of the respiratory nurses make use of the semi-structured questionnaires. The other tools used by the respiratory nurses have been the measurement tool that is utilised for measuring the human rate of respiration. The rate of respiration rises with the fever or other adverse medical conditions. Therefore, it is quite significant for the nurses to regularly measure the rate of respiration of the patients in the respiratory ward. In a few of the measurements the patient is required to breathe normally and quietly. In most of the measurements, the respiratory nurses may require the patients to take forced inhalation as well as exhalation after taking deep breaths (Medline Plus, 2011). There are various health assessment tools that are used by the nurses so that they are capable of gathering the information related to patients diagnosis and care plan. One of them is patients charts through which information related to the health of the patient can be accessed. Charts may consist of treatment plan, medical history of the past and current medical condition along with other data that may be useful for creating a care plan. Vital sign is also one of the tools of assessment that is used by nurses in order to monitor the heart rate, temperature, blood pressure and respiratory rates of the patient. With this tool the life threatening complications can be prevented and thus the overall mental as well as physical state of the patient can be recognised. Patient’s interview is yet another significant assessment tool. It is significant to conduct the interview with the patient so that the nurses can learn regarding the physical and mental status of the patient. Short interview can as well be helpful if conducted throughout the day by asking the patient regarding their status on that particular day. Each time when the nurses interact with the patients they acquire the necessary information regarding their progress. This is possible by closely observing the patients that assist them in realising the pain, reaction to pain as well as emotional disturbances. By observing the patients, it becomes easier for the nurses to understand the patients at times may not be able to communicate their problems (Scribd, 2009). The patients who have pneumonia tends to be either symptomatic or asymptomatic, therefore it becomes essential for the practitioners to identify how severe are the patients and the impacts of pneumonia on the physical conditions. In such kind of situations CURB-65 is one of the most used tools in order to assess if the patient is sick or there is likelihood of the patient becoming unwell in the near future, requiring admission to ICU. A point is allocated for abnormal findings in four main peripheries such as blood urea level, blood pressure, mental state and respiratory rate thus providing score for age. In CURB-65, C stands for new mental confusion, U stands for Urea>7mmol/l, R stands for respiratory rate, B stands for blood pressure and 65 denotes age which is greater than 65. The patients, who have obtained 2 or less, may not necessarily require to be admitted in the hospital until and unless the patients have any kind of pre-existing illness that can worsen the problem. However, the patients who have acquired a score of more than 2 needs to get admitted in the hospital for further evaluation and management. It can be stated that if the score is higher than 2 the case tends to be quite life-threatening. One of the assessment tools that are being utilised in the current practice is CURB-65 score. If CURB-65 is be used along with MEWS which is Modified Early Warning Score, the effectiveness of CURB-65 is enhanced. The cumulative score obtained can be based upon the consciousness level, blood pressure, temperature, urine output and pulse. It can further be mentioned that when such assessment tools are used, it assists in locating the deterioration held in patients and thus makes possible intervention to ICU at early stage. Furthermore, if they are used along with the haematological and biological parameters, then in such cases it becomes possible for the nurses to identify the early organ failure. By making of the tools such as MEWS and CURB-65, it becomes possible for the nurses to assess how severe is pneumonia and thus take steps through which the disease can be treated on time. Through chest X-Ray a person is capable of identifying if the patient has any underlying lung disease thus exacerbating the issue (Watson, 2008). 4.0. Examination of the Relationship between the Theories of Decision Making In the Provision of Nursing Care Delivery People tend to define the concept or practice of nursing in different ways from varying perspective. While few describe it as a profession, others demonstrate it as a passion. On the basis of theoretical tenets of nursing, scholars have also introduced various definitions in relation to the practice. However, Nightingale described, “taking charge of the personal health on an individual and to put the individual in the best possible state and allow nature to act upon him” (Meleis, 2011, pp. 106). Based on the similar ground, the International Council of Nurses demonstrated the concept as the profession in which the nurses take care of individuals who are unable to take care of themselves in terms of physical as well as mental health (Meleis, 2011). Notably, these two definitions or descriptions of nursing were presented in two different eras of medical science and from two dissimilar perspectives. However, in both the instances, the significance of rendering care can be observed apparently in the profession of nursing. Considering the fact that care is one of the essential and principle elements of nursing, various models and theories had been developed by the experts with the intention to provide a comprehensive and systematic framework in nursing care delivery system (Neisner & Raymond, 2002). However, it largely depends on the decision making of the professionals regarding the selection of appropriate processes to be followed with the intention to render quality care to the individuals who are in need. This signifies that the nurses require gaining sufficient and effective expertise in their fields of decision making (Burhans & Alligood, 2010). It is in this context that nurses shall consider the influence of reflective learning in order to enhance their understanding of the situation and gaining confidence in decision making. As stated by Heath (1998), nursing is a profession which is not only based on the academics and research abstracts but also emphasises on the practice based experiences of the professionals to facilitate the accuracy in decision making process. It is worth mentioning that reflection learning proves to be highly beneficial for nurses in enhancing their proficiency in decision making processes related to nursing care delivery (Heath, 1998). In this regard, the frameworks of reflective learning as presented by various experts shall be quite effective for the nurses to direct their professional experiences for better efficiency in decision making. For instance, the John’s model of reflection which was introduced in the 1994, signifies five phases in order to comprehend the learning gained by an individual from his/her experience and relate the learning with his/her academic understanding. Thus, this framework intends to assist the individual in developing their confidence and expertise in decision making and shall also prove to be quite effective in the profession of nursing as well (Jasper, 2003). The five interrelated phases as considered in the John’s model are related to the description of the experience, reflection of the gap between the aims intended to achieve and the attributes achieved, the influencing factors to cause the gap, the alternative strategies that would have been considerably more effective, and summarising of the learning gained from the experience (Jasper, 2003). To represent the fact diagrammatically, Source: (University of Turku, n.d.). Therefore, the model can be termed as a cyclical process that tends to direct the self-learning of a nurse and in turn enhance her expertise in quality care delivery through effective decision making. There are various other models that are used for reflective learning by professionals in various fields and shall also be beneficial in the nursing care delivery system such as the Kolb’s learning cycle and the Atkins and Murphy’s model of reflection (University of Turku, n.d.). Kolb’s learning cycle also emphasises on learning from the experiences gained by an individual which has been noted to be quite significant in service sector similar to that of nursing. According to Kolb’s experiential learning theory, individuals tend to develop their reflection on the basis of their concrete experiences acquired through academic or prior work practices. These reflections are later used to frame an abstract concept regarding the learning attained by the individual. These implications can be then effectively tested in order to enhance the concrete experiences (Sternberg & Zhang, 2000). This continuous process of learning shall also be implemented in the context of nursing to develop the expertise and accuracy in decision making of the professionals. In the similar context, the Atkins and Murphy’s model of reflection also emphasises on the analogous aspect of acquiring more realistic knowledge regarding the job responsibilities. The effectiveness of these models is to have significant impact on the knowledge of the clinical service providers in relation to a particular situation. This can be well-observed with reference to the comment of Zuzelo (2007), “the models encourage the practitioners to consider a situation in clinical practice” (pp. 4). 5.0. Determination Of The Effectiveness Of The Clinical Decision Making Decision making in relation to effective clinical practice is considered to be a vital aspect that determines the success of therapeutic assessments of the clinical encounters. In other words, it can be stated that the effectiveness of clinical therapeutic analysis and success in the remedial treatment is largely depended on the accuracy in clinical decision making (Politi & Et. Al., 2007). It is in this context that the experiences and knowledge of clinical practitioners and the nurses can be termed as quite crucial elements in the decision making process. As stated by Sque & Et. Al. (2009), the effectiveness and accuracy of the clinical decision making depends largely on the “fully informed assessments and astute, analytic judgements” made by the clinical practitioners (Hall & Et. Al., 2009, pp. 235-252). This demands sufficient knowledge of the clinical practitioners regarding the particular diagnosis (Hall & Et. Al., 2009). There are various other factors that are termed to influence the decision making process in clinical practice. For instance, the decisions or judgements considered by the medical practitioners are often recognised to be based on their intuition in the initial stage which gradually tends to be more realistic and accurate. Nyatanga & Vocht (2008) stated that intuition assists the medical practitioners, operating in acute and complex situations such as in the respiratory wards, to take decisions on the basis of their intuition. It is further stated by the authors that intuition posses cognitive as well as physiological bases which are apparently observable and assists the practitioners in understanding a particular situation. It is worth mentioning that decision making on the basis of intuition should also be ethical to derive benefits (Nyatanga & Vocht, 2008). Ethical considerations in terms of decision making can be apparently stated as quite essential in the context of clinical practices. According to Kollemorten & Et. Al. (1981), a clinical decision fundamentally comprises of ethical components. The aspect becomes quite apparent during the development of a remedial planning through decision making on the basis of their knowledge and expertise. It is in this context that the authors signify the concept of value judgement that is intended towards the assessment of either the probable consequences caused due to the decision making, or the fulfilment of the duties of the practitioners along with the rights of the clinical patients (Kollemorten & Et. Al., 1981). Considering these factors, clinical decision makers have often been witnessed to opt for collective decision making, i.e. with the consent of other practitioners as well as with other concerned parties of the patient. The concept of collective decision making is considered as a process where the information regarding the decision to be taken and its probable consequences are conveyed to the concerned parties. In this context the intention is to derive their consent or recommendations to enhance the effectiveness and accuracy of the decision making (Frosch & Et. Al., 1999). The communication of the various uncertainties in relation to the decision making in clinical practice, have been recognised to be quite beneficial by various practitioners. As stated by Politi & Et. Al. (2007), with due consideration to the virtues of shared process of decision making, practitioners are providing rapidly increasing significance to the communication of the pros and cons in relation to the therapeutic analysis. The risk of uncertainty in clinical decision making is termed to be a common phenomenon. One of the significant reasons to cause the limitation of uncertainty in medical practices can be apparently recognised as the individuality of each case (Hall & Et. Al., 2009). From an overall perspective, it is quite apparent that the effectiveness of clinical decision making largely depends on the knowledge and expertise of the practitioners. The accuracy of the decision making process is also influenced by the intuition of the clinical practitioners to a large extent. Another most significant aspect in the clinical decision making process can be recognised as the concept of ethical considerations. These aspects are also likely to be influenced by the factors of uncertainty associated with the decision making process in clinical practices in order to provide effective treatment to the patients for the betterment of their health. However, an insight to this context reveals that influencing factors such as intuition, ethical considerations and overall efficiency in the therapeutic assessment depend on the knowledge of the practitioners to a significant extent (Kollemorten & Et. Al., 1981; Frosch & Et. Al., 1999; Nyatanga & Vocht, 2008). Considering these factors it can be stated that reflection shall assist the medical practitioner in developing his/her knowledge as well as conscience which in turn is likely to facilitate the efficiency of the decisions adopted by the practitioner(s). As stated by Ylvisaker & Et. Al. (2002), evidence-based practice through the experiential learning in medical decision making is quite effective in understanding the therapeutic requirements for a particular disease in relation to a particular population. Therefore, emphasising on reflective learning models such as the Kolb’s model, John’s model of reflection and other models shall be quite effective in this context. 6.0. Conclusions and Recommendations Regular operations in the respiratory ward require intense consideration to the aspect of effective treatment for the clinical patients. In most of the instances, the nurses working in the respiratory ward require to take decisions regarding the patient’s therapeutic assessment and urgent treatment in case of urgencies. It is worth mentioning that assessment plays a crucial role in directing decision making process in clinical practices through the proper implementation of assessment tools in terms of observation or questioning and measuring. The objective in assessing and implementing the assessment tools can be observed as to be related with the identification of the various aspects of the particular clinical situation. Furthermore, efficient diagnosis and assessment of the situation is also required for the decision making process. It is in this context that nurses working in respiratory wards shall require taking decisions regarding the treatment of a clinical patient in case of urgency which is again subjected to the knowledge and expertise of the clinical practitioners. Therefore, it is quite essential for the nurses working in respiratory ward, to gain efficiency in terms of knowledge regarding a particular clinical problem. Moreover, with due consideration to the aspect of individuality in clinical problems it can be stated that nurses require gaining expertise in dealing with the circumstances through continuous development of their knowledge. The implications of assessment tools such as observation, questioning and measuring as well as experiential learning shall be considered as quite effective to develop the knowledge and expertise among nurses in the respiratory ward. From an in-depth point of view, it can be stated that learning through reflection shall enhance the expertise of the nurses in understanding the probable consequences of the decision undertaken as well as would develop their ethical conscience. This in turn shall minimise the risk of conflicts and subsequently would enhance the efficiency in the decision making process. In this regard, the practitioners shall provide significant consideration to the implications of reflective learning models with the purpose to identify their deficiencies and thus develop their expertise. However, ethical considerations such as the transference of information to the concerned parties including the patient party and other medical practitioners as well should also be emphasised in the clinical decision making process. References Boblin-Cummings, S. & Et. Al., 1999. Critical Elements in the Process of Decision Making: A Nursing Perspective. Nursing Leadership. Vol: 12, Iss: 1, pp: 6-13. Burhans, L. M. & Alligood, M. R., 2010. Quality Nursing Care in the Words of Nurses. Journal of Advanced Nursing, Vol: 66, pp. 1689-1696. College & Association of Registered Nurses of Alberta, 2005. Nursing Practice Standards. Nursing-A-Self-Regulating Profession. [Online] Available at: http://www.nurses.ab.ca/pdf/Nursing%20Practice%20Standards.pdf [Accessed September 06, 2011]. Degrees Finder, 2011. How to Become a Respiratory Nurse. What Does A Respiratory Nurse Do? [Online] Available at: http://www.degreefinders.com/education-articles/careers/how-to-become-a-respiratory-nurse.html [Accessed September 06, 2011]. Frosch, D. L. & Et. Al., 1999. Shared Decision Making in Clinical Medicine: Past Research and Future Directions. American Journal of Preventive Medicine, Vol: 17, pp. 285–294. Gatsmans, C. & Et. Al., 1998. “Nursing Considered As Moral Practice: A Philosophical-Ethical Interpretation Of Nursing”, PubMed. Vol: 8, Iss: 1, pp: 43-69. Georges, J. & Grypdonck, M., 2011. “Moral Problems Experienced By Nurses When Caring For Terminally Ill People: A Literature Review”, Nursing Ethics. Hall, M. & Et. Al., 2009. A Foundation for Neonatal Care: A Multi-Disciplinary Guide. Radcliffe Publishing. Hardy, D. & Smith, B., 2008. “Decision Making in Clinical Practise”, British Journal of Anaesthetic and Recovery Nursing. Vol: 9, Iss: 01, pp: 19-21. Heath, H., 1998. Reflection and Patterns of Knowing in Nursing. Journal of Advanced Nursing, Vol: 27, pp. 1054-1059. Jasper, M., 2003. Beginning Reflective Practice. Nelson Thornes. Kennedy, S., 2007. “Detecting Changes in the Respiratory Status of Ward Patients”, Nursing Standards. Vol: 21, Iss:49, Pp: 42-46. Kollemorten, I. & Et. Al., 1981. Ethical Aspects of Clinical Decision-Making. Journal of Medical Ethics, Vol: 7, pp. 67-69. Leininger, M. M., 1990. Ethical and Moral Dimensions of Care. Wayne State University Press. Meleis, A. B., 2011. Theoretical Nursing: Development and Progress. Lippincott Williams & Wilkins. Medline Plus, 2011. Pulmonary Function Test. Health Topics. [Online] Available at: http://www.nlm.nih.gov/medlineplus/ency/article/003853.htm [Accessed September 10, 2011]. Neisner, J. & Raymond, B., 2002. Nurse Staffing and Care Delivery Models: A Review of the Evidence. Kaiser Permanente Institute for Health Policy. Nursing Times, 2007. End-Of-Life Decisions And Respiratory Disease. Nursing Practice. Vol: 102, Iss: 07, pp: 56. Nyatanga, B. & Vocht, H. De., 2008. Intuition in Clinical Decision-Making: A Psychological Penumbra. International Journal of Palliative Nursing, Vol: 14. Politi, M. C. & Et. Al., 2007. Communicating the Uncertainty of Harms and Benefits of Medical Interventions. Medical Decision Making, Vol: 27, pp. 681–695. Royal College of Nursing, 2004. Nursing Assessment and Older People. Introduction. [Online] Available at: http://www.rcn.org.uk/__data/assets/pdf_file/0010/78616/002310.pdf [Accessed September 06, 2011]. Rafferty, S. R. N., No Date. The Role of Respiratory Nurse Specialist. Abstract. [Online] Available at: http://www.capscursos.com.br/docs/Nurse.pdf [Accessed September 06, 2011]. Schwab, N. & Gelfman, M. H., 2005. Legal Issues In School Health Services: A Resource For School Administrators, School Attorneys, School Nurses. Iuniverse. Scribd, 2009. Nursing Process. Introduction to Nursing. [Online] Available at: http://www.slideshare.net/jh_ajj/nursing-assessment [Accessed September 06, 2011]. Sternberg, R. J. & Zhang, L. F., 2000. Perspectives on Cognitive, Learning, and Thinking Styles. Lawrence Erlbaum. University of Turku, No Date. Using a Model of Reflection. AHOT. [Online] Available at: http://www.ahot.utu.fi/yliopistot/materiaali/index/using_a_model_of_reflection.pdf [Accessed September 05, 2011]. Watson, A. D., 2008. Pneumonia 2: Effective Nursing Assessment and Management. Nursing Times. [Online] Available at: http://www.nursingtimes.net/nursing-practice-clinical-research/pneumonia-2-effective-nursing-assessment-and-management/811709.article [Accessed September 06, 2011]. Wheeldon, A., 2005. Exploring Nursing Roles: Using Physical Assessment In The Respiratory Unit. Pubmed. Vol: 8, Iss: 14, pp: 571-574. Ylvisaker, M. & Et. Al., 2002. Reflections on Evidence Based Practice and Rational Clinical Decision Making. Journal of Medical Speech-Language Pathology, Vol: 10, pp. 25-33. Zuzelo, P. R., 2007. The Clinical Nurse Specialist Handbook. Jones & Bartlett Learning. Read More