Clinical Decision Making: Blood Culture from Patient with Acute Leukaemia - Essay Example

of the of the Nursing 3 June, Clinical decision making Introduction: Decision to take blood culture from patient with acute leukaemia In a hypothetical case scenario, a nurse encounters a patient of acute leukaemia with fever. His or her decision to send or not to send patient’s blood for culture is being subjected to analysis as a part of the case study analysis of clinical decision making. The clinical reasoning behind the decision, the factors affecting the decision, effectiveness and implication of this decision are all components of this analysis. Fever frequently affects patients with haematological malignancies such as leukaemias, either as a part of the disease process itself or because of the chemotherapeutic drugs used in the treatment. To diagnose the cause, blood culture is mostly required for identification of causative bacteria or fungus. A nurse caring for a patient with acute leukaemia is many a time confronted with the clinical scenarios where he or she is required to make clinical decision to take blood culture from a febrile patient. The nurse may herself make the decision to obtain a blood sample for culture on suspicion of an infection or may act on the orders of a physician. In an autonomous decision, the complexity and the nature of the decision task affect the approach taken towards problem solving (Thompson, Kirkness & Mitchell 2007). The decision taken by the nurse can be analysed for the application of evidence based medicine in routine clinical situations. Analysis and clinical reasoning of the decision Decision analysis allows to share a decision with seniors and colleagues and to evaluate its advantages and disadvantages (Bucknall 2003). Nurse uses the domains of prior knowledge about the patient and his circumstances, ethical knowledge and specific knowledge. This knowledge is accessed and applied by the means of pattern recognition and heuristics (Bohinc & Gradisar 2003). First of all, the component of problem recognition requires the nurse to identify the ‘cues’ or clinical symptoms such as fever in this case. The recall of these cues leads to formulation of a hypothesis of a problem (Jenks 1993). Once the problem has been recognised, the decision maker proceeds on to the next step of assessment in which the data is gathered, assimilated and analysed (Klein 2005). The nurse records the temperature, maintains a temperature chart and records associated symptoms such as chills, sweating, cough and pattern of fever etc. as a part of data collection. To be able to form a judgement, it is imperative to evaluate and make a choice (Higgs et al 2008; Connolly, Arkes & Hammond 2000). The nurse evaluates the data and infers about what should be done (Thompson & Dowding 2004). The judgement can be of a bacteremia as the cause of fever. To make an operational decision, in the scenario of management of a febrile patient with acute leukaemia, the nurse compares the requirement of a blood sample for blood culture with the alternative of not taking a sample using a clinical decision analysis. To be able to reach a decision, nurse has to explore and compare the advantages and disadvantages of this diagnostic tool in this patient (Standing 2009). Decision making is the process whereby knowledge is converted into action. The more accurate the knowledge, the more relevant and accurate a decision is likely to be (Randall et al 2009). This impacts the clinical practice of the nurse. The knowledge base about the complex associations between infections, signs and symptoms of infection such as fever, scenario of an immunocompromised and/or neutropenic patient, is acquired as a part of nursing training, with the experience of dealing with such patients and the usual protocols and guidelines followed in a setup. Clinical reasoning in this case, is most likely a combination of knowledge base, experience and intuition (Tanner et al, 1987). Also, if the nurse’s actions are analysed using a rational model, the objective of the decision is to find out whether infectious agent is present in the blood. To achieve this objective, the strategy the nurse employs is to take a blood culture. If successful, patient’s condition improves at the cost of a blood test. However, it is too simplistic a model for decision analysis. Factors affecting the decision Many factors at the workplace affect clinical reasoning. Some of them are external such as legal, ethical, social, organisational and physical. Many are ‘internal’ such as heuristics and biases, and expertise of the nurse. All these factors can influence the judgment choices. Legal factors in this case could be related to consent. Before actually implementing the decision, the nurse has to obtain consent from the patient by satisfying his queries about pain and the needles used for the collection of blood, the usefulness and implication of test results. Ethical factors relate to the dilemma faced by a nurse regarding the utility of performing a diagnostic test in such a patient. Social factors are as a result of working in a team. For example, the nurse may get influenced by what her colleague in the same ward or under similar situations does. Working techniques, methods and experience of co-workers can act as an important factor by which the nurse in this case decides to take or not take blood culture. Organisational factors pertain to the workload and policies and protocols. If the nurse is overworked and the time she can devote to a particular patient is less, she may prioritise a life saving action over a diagnostic action (Hedburg & Satterlund 2004). The sampling decision may be relegated to a later time. Also, interruptions over a workplace allow less time to be devoted to decision making process. Organisational protocols may also dictate certain criteria which when present dictate the conduct of such diagnostic tests. Additionally, the availability of physical resources may influence the decision taken in this case. The nurse has to know and decide about the facility of the equipment needed for obtaining a blood sample, culture media and the transport of the samples to the laboratory (Varcoe 2003). Out of the internal factors, the most crucial factor that influences the quality of a decision is the level of the expertise of the nurse. An experienced nurse has a different approach towards decision making than a novice or a student nurse. Their knowledge base is wider and they are more flexible and structured when it comes to decision making. A novice may first seek confirmation from a supervisor before taking blood culture about the need, the timing and the technique. A novice may make the decision to take the blood sample when it si not clinically indicated or vice versa (Ebright, Urden & Patterson 2004). Personal biases, such as those that may exist in the mind of a nurse such as relating to critically or terminally ill oncology patients may affect her decision to take or not take the blood culture. Heuristics or the ‘mental shortcuts’ that the nurse applies to reach a decision may lead to a decision that is based on a limited amount of information or information applied in a limited context ( Buckingham & Adams 2000). Thus, clinical decision making is not done in an isolated context. In fact, it is vulnerable to and moulded by various external and internal factors which lend new dimensions to a decision and the behaviour of the decision maker. The nurse’s decision about blood culture is bound to get influenced by all these factors. Effectiveness of the decision Whether the decision is effective or not again depends upon the knowledge and the evidence it is based upon. Safety of the decision is evaluated in terms of the commission or omission of the act causing harm to the patient. If the cause of the infection goes undetected in the patient in the absence of blood culture and leads to morbidity or mortality, then it is considered an unsafe decision on the nurse’s part. However, in case, other alternative diagnosis for fever are more likely and they are under prioritised in favour of a blood culture, then the commission of this act is also unsafe. In this case, the decision is inappropriate in terms of financial and resource utilisation. The effectiveness of a decision can be expanded with feedback and clinical supervision. The nurse can be guided in her decision by her supervisors which may be a senior member of the nursing staff or the physician. Implication of the decision To make a better decision, it is important to have a knowledge base from which all the information can be retrieved. This base can be expanded by having access to, reading and incorporating evidence based knowledge in day to day clinical practice (Thompson & Dowding 2004). Knowledge of latest updates and guidelines regarding blood cultures in leukaemic patients presenting with fever can enhance the clinical decision making skills of the nurse relevant to this case. Senior personnel’s opinion and experience can also be sought. The decision taken by the nurse and its analysis is helpful to gain an insight into the way the nurse processes the information and generates the action. It attempts to define the models of information utilisation in clinical decision making (Thompson et al 2004). There is an increasing need for an analysis of the clinical decision making process applied by the nurses and application of evidence based practices to this decision making. There also exists the need for application and further exploration of the existing decision making models to clinical interventions. Only then these interventions will be put in to operation using evidence based knowledge and the barriers to their employment can be understood and managed, Reference List Bucknall, T 2003, ‘The clinical landscape of critical care: nurses’ decision making’, Journal of Advanced Nursing, vol. 43, no. 3, pp. 310–319. Bohinc, M & Gradisar, M 2003. Decision-making model for nursing. Journal of Nursing Administration’, vol. 33, no. 12, pp. 627–629. Buckingham, CD & Adams, A 2000, ‘Classifying clinical decision making: interpreting nursing intuition, heuristics and medical diagnosis’, Journal of Advanced Nursing, vol. 32, no.4, pp. 990–8. Connolly, T, Arkes, H, Hammond, K 2000, Judgement and decision making: an interdisciplinary reader, 2nd edn. 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