Reflective Analysis of a Clinical Decision - Case Study Example

REFLECTIVE ANALYSIS OF A CLINICAL DECISION Introduction: The patient, a Caucasian female thirty-five years old, had presented at the Family Planning Clinic for the purpose of getting a course of oral contraceptives. Long-Acting Reversible Contraception was advised to the patient instead of starting on a self-medicated regimen of third generation oral contraceptives, which had a history of producing harmful side-effects. Long-acting reversible contraception is defined as methods that require administration less than once a month or once in a cycle. The National Institute for Clinical Excellence had commissioned the National Collaborating Centre for Women and Children’s Health to develop a clinical guideline on long-acting reversible contraception for women for use by the National Health Service (NHS) in England and Wales (Web site of National Institute for Health and Clinical Excellence)1. The National Institute for Health and Clinical Excellence guideline offers the best-practice advice for all women of reproductive age who may wish to regulate their fertility by using the long-acting reversible contraceptive methods.2 (Clinical Guideline 30, 2005: pp.4-5). The copper intrauterine device was selected for the patient, as it had minimal side-effects. Discussion: THE EPISTOMOLOGY OF PRACTICE: Professional knowledge comprising of: The reasoning process, the importance of reflection in understanding the decision taken and the procedure followed. Knowledge of all the different forms of long-acting reversible contraception available, their individual uses and procedures for application, and the reasons why the selected method is preferable to third generation oral contraceptives. CLINICAL REASONING: Beck et al (2004: p.12), state that logical reasoning combines experience, intellectual faculties and formal systems of thought. Inductive reasoning is the process of developing generalizations from specific observations. Deductive reasoning is the process of developing specific predictions from general principles. The validity of reasoning depends on the accuracy of information with which one starts. The warning against the use of oral contraceptives of the third generation group was arrived at by the process of deductive reasoning. According to Newble, et al, Chap.16, (Higgs; Jones (eds) 2000: p.156), clinical reasoning is one of the three components which comprise clinical competence; the other two components are: relevant knowledge and relevant skills – which includes interpersonal, clinical and technical skills. Clinical reasoning can be considered to be the intellectual activity which synthesizes information obtained from the clinical situation, integrates it with previous knowledge and experience, and uses it for making diagnostic and management decisions. Corcoran-Perry; Narayan (Chap.28), (Higgs; Jones (eds) 2000: p.249) state that nurses use clinical reasoning to make both autonomous and collaborative, interdisciplinary judgements about patient care. It is estimated that about 30% of pregnancies are unplanned (Clinical Guideline 30, 2005: p.4). The effectiveness of the barrier method and the oral contraceptive pills depends on their correct and consistent use. By contrast, the effectiveness of long-acting reversible contraceptive methods does not depend on daily concordance. In the category of Long-Acting Reversible Contraception, the different methods comprise of the following: (1) Copper-intrauterine device. (2) Progestogen-only intrauterine systems. (3) Progestogen-only injectable contraceptives. (4) Progestogen-only subdermal implants. (5) Combined vaginal rings. (Clinical Guideline 30, 2005: p.4). Women considering long-acting reversible contraceptive methods, should receive detailed information both verbal and written, that will enable them to choose a method and use it effectively (p.6). Healthcare professionals advising women about contraceptive choices should be trained in the contraceptive area such as intrauterine or subdermal contraceptives, so that they are competent to help women to consider and compare the risks and benefits of all methods relevant to their individual needs, and to manage common side effects and problems (p.7). Third Generation Oral Contraceptives and Venous Thromboembolism (blood clots in the veins): 3The Department of Health bulletin (p.1) gives the following information and advice: Venous thromboembolism is a very rare problem that may occur in any woman whether she is taking the Pill or not. It has long been known that the risk of venous thromboembolism is slightly higher in women taking any combined oral contraceptive pill, compared to those not on the Pill. This risk is very small and is far lower than the risk venous thromboembolism in pregnancy. (Web site of Medicines and Healthcare Products Regulatory Agency). The European Medicines regulators (the Committee for Proprietary Medicinal Products have concluded that women who use ‘third generation’ combined oral contraceptives ( Femodene, Femodene ED, Femodette, Marvelon, Mercilon, Minulet, Triadene and Tri-Minulet) are at a slightly higher risk of developing venous thromboembolism than those who use other types of pills known as ‘second generation’ pills. All combined oral contraceptive pills contain two hormones: oestrogen and progestogen. The different types of pills are known as second or third generation contraceptives depending on the type of progestogen they contain. The second generation pills referred to here contain the progestogen levonorgestrel. In the third generation pills the progestogen is either desogestrel (Marvelon and Mercilon) or gestodene (Fenodene, Femodene ED, Femodette, Minulet, Triadene, and Tri-Minulet). Venous thrombosis occurs when clots of blood form in the veins, usually in the calf, causing a red, swollen and often painful leg. Rarely these clots might move and travel through the bloodstream, a process called venous thromboembolism. The Clinical Guideline 30 (2005: p.4) states that the use of long-acting reversible contraceptive is low in Great Britain, as compared to the use of oral contraceptives. Their current limited use suggests that health-care professionals need better guidance and training, so that they can help women make an informed choice. REFLECTION: Todd, Gillian (Chap.4), Johns; Freshwater(2006: p.38), state that reflection is both subjective and particular. It is a fusion of sensing, perceiving, intuiting and thinking, related to a specific experience, in order to develop insights into self and practice. Reflection is purposeful, vision-driven, and intends to resolve contradiction. Reflective practice (p.38) as a model for clinical supervision is a well- established process in the training and professional development of nurse practitioners. The aims of reflective practice is to help guide the supervisee through a process of learning and discovery. The supervisee learns to reflect on-action through recalling and revisiting past events with an aim of learning from their experiences towards developing a new understanding of themselves and the situation. In time, through the process of clinical supervision, the reflective practitioner learns to reflect in-action. As in the case of educators and teachers, state Leppa; Terry (2004: pp.195-196), reflective practice is equally relevant to nurse clinicians who have been encouraged to reflect on the way they deliver care, so as to identify weaknesses, build on strengths and develop best practice. Within ethics teaching, reflection has become central to understanding the nature of ethical dilemmas, and how they impact on those involved. DECISION MAKING: The ability to reach successful decisions is based on accurate evidence and valid reasoning. Behaviours based on critical thinking are essential to a nurse’s role as clinician, manager, researcher or teacher (Swansburg, 2002: p.1). Cognitive, intuitive and experiential theories of decision making. Hardin; Kaplow (2004: p.57) state that clinical judgement is at the heart of nursing. 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. Nurses use reflection and critical thinking as they make the best decision for the patient given the context of the situation. 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. According to Thompson; Dowding (2002: p.2), healthcare decision making is associated with uncertainty, and healthcare professionals have to deal with this uncertainty in their decision making. Key policy drivers have led to the development of 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. Taylor (1997: p.329) states that problem solving in clinical nursing practice is the essence of good care delivery. The commonly used methods for problem solving are: trial and error, intuition, experimentation and the scientific method. 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. According to Benner, et al (1996: p.xix), the vast majority of research on clinical judgment, and on educational approaches to improve it, focuses on three criteria: deliberative, conscious and analytic approaches. In nursing, the terms: “clinical decision making”, “nursing process”, “clinical problem solving” and more recently “critical thinking” refer to the same process, and can be used interchangeably. 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. USE OF EVIDENCE IN CLINICAL DECISION MAKING: Nurses increasingly are expected to adopt an evidence-based practice (Beck, et al, 2004: p.4), which is broadly defined as using the best clinical evidence in making patient care decisions. There is consensus that research findings from rigorous studies constitute the best type of evidence for informing nurses’ decisions, actions and interactions with clients. Rashotte; Carnevale (2004: p.161) assert that few issues prevail today in the health-care profession that have evoked as much controversy as that surrounding knowledge utilization and evidence-based practice. This is due to the perceived threat of evidence-based practice to the individual practitioner’s decision making process, and thus individual autonomy and authority. Evidences against the other contraceptive methods, show that the copper implant is the safest. According to Anderson (2004: p.72), the purpose of an implant is to provide very long term protection, up to five years, while still maintaining fertility. The implant can be removed earlier if so desired. Once inserted, the implant requires no further attention by the user. Lactating women or women who cannot use estrogen for medical reasons, can safely use an implant (Hatcher et al,1998, cited in Anderson (2004: p.72). 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 United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), which is established under statute (Nurses, Midwives and Health Visitors Act 1997. There has been an increase in the number of negligence actions against healthcare professionals, and proposals concerning Human Rights Act 1998 (Tingle; McHale 2001: pp.1-2). According to McGivern et al (2003: p.256) self-determination in health-care requires understandable information, fully informed consent, and responsibility for the outcomes of one’s choices. Motivation for self-care is the primary goal. ETHICAL ASPECTS OF CLINICAL DECISIONS: Patient autonomy is the potential for self-determination, and can be exercised when the patient has the necessary information to consider treatment which is consistent with their beliefs and wishes (Edwards, 1997, quoted in Bartter, 2001: p.34). In nurse-led family planning clinics, counseling women who experience an unwanted pregancy is perhaps one of the most challenging consultations that a practitioner undertakes. An informed decision can only be made when the woman receives enough information on the different options available. The practitioner requires ethical knowledge to provide insight into this moral and ethically charged situation. Empowerment is a fundamental ethic and should be uppermost on the agenda in a nurse-led family planning service. Caring and client advocacy are essential attitudes that a nurse should practise (pp.33-34). REFLECTIVE ACCOUNT: The Caucasian middle-aged patient was advised about the various forms of long-acting reversible contraceptives that were available, and she was informed that the copper uterine implant would not create health complications like the other methods which functioned on a chemical basis. She was asked to avoid the third generation oral contraceptive pills that she had come to the clinic for, and their possible ill-effects on the clotting of blood in the veins leading to venous thromboembolism, which was explained to her. Critical thinking based on accurate evidence and valid reasoning helped in the decision making process, concerning the selection of the copper device as the safest method of contraception. The sharing of information helped the patient to make up her mind regarding her choice of method. Conclusion: The role of the family planning nurse practitioner is a specialized one, involving counseling, examining, diagnosing, and treating patients attending City Health Centres for family planning and gynaecology services4. As stated by Thompson; Dowding (2002: p.5), nurses are taking on new roles: health promoters, giving diagnostic and prognostic information to patients, assessing health risks and screening for early signs of treatable disease. According to Rowlands, et al (1997: p.35), unlike in the past, the practice nurse is now becoming recognized as an accessible health professional. The implications for future role development are: developing specialized nursing care for various departments of the healthcare system with greater guidance. REFERENCES Anderson, Barbara A. (2004). Reproductive Health: Women and Men’s Shared Responsibility. Jones and Bartlett Publishers. Albarran, John W; Scholes, Julie; Williams, Caroline. (2006). Developing Expertise in Critical Care Nursing. Blackwell Publishing. Bartter, Karen. (2001). Ethical Issues in Advanced Nursing. Elsevier Health Sciences. Beck, Denise F. Polit; O’Hara, Denise Polit; Beck, Cheryl Tatano. (2004). Nursing Research: Principles and Methods. Lippincott Williams & Wilkins. Benner, Patricia E; Chesla, Katherine A; Tanner, Christine A. (1996). Expertise in Nursing Practice: Caring, Clinical Judgment and Ethics. Springer Publishing. Clinical Guideline 30 ( 26th Octobr, 2005). Long-acting reversible contraception. Developed by the National Collaborating Centre for Women’s and Children’s Health. Web site: http://www.nice.org.uk/guidance/CG30/niceguidance/pdf/English Corcoran-Perry, Sheila; Narayan, Suzanne (Chapter 28: Teaching Clinical Reasoning in Nursing Education), Higgs, Joy; Jones, Mark A. (Eds) (2000). Clinical Reasoning in the Health Professions. Elsevier Health Sciences. Hardin, Sonya R.; Kaplow, Roberta. (2004). Synergy for Clinical Excellence: The AACN Synergy Model for Patient Care. Jones and Bartlett Publishers. Leppa, Carol J; Terry, Louise M. (2004). “Reflective Practice in Nursing Ethics Education: International Collaboration”. Journal: Journal of Advanced Nursing, Vol.48, No.2, pp.195-202. McGivern, Diana O; Sullivan Marx, Eileen M; Mezey, Mathy D. (2003). Nurse Practitioners: Evolution of Advanced Practice. Springer Publishing. Medicines and Healthcare Products Regulatory Agency. Web site: For Venous Thromboembolism (Blood Clots in the Veins) and Third Generation Oral Contraceptives: Advice and Information from the Department of Health. http://www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&useSecondary=true&ssDocName=CON2015734&ssTargetNodeId=22 Newble, David; Norman, Geoffrey; Vleuten, Cees van der (Chapter 16: Assessing Clinical Reasoning), Higgs, Joy; Jones, Mark A. (Eds) (2000). Clinical Reasoning in the Health Professions. Elsevier Health Sciences. Rashotte, Judy; Carnevale, F.A. (2004). “Medical and Nursing Clinical Decision Making: A Comparative Epistemological Analysis”, Journal: Nursing Philosophy, Vol.5, pp.160-174. Rowlands, Sam; Mehigan, Shelley; Sutherland, Catriona; Pettifer, Maggie. (1997). Managing Family Planning in General Practice. Radcliffe Publishing. Swansburg, Russell C. (Ed.), (2002). Introduction to Management and Leadership for Nurse Managers. Jones and Bartlett Publishers. Taylor, Catherine. (1997). “Problem Solving in Clinical Nursing Practice”. Journal: Journal of Advanced Nursing, Vol.26, pp.329-336. Thompson, Carl; Dowding, Dawn. (2001). Clinical Decision-Making and Judgement in Nursing. London: Churchill Livingstone. Tingle, John; McHale, Jean Vanessa. (2001). Law and Nursing. Elsevier Health Sciences. Todd, Gillian (Chapter 4: Reflective Practice and Socratic Dialogue). Johns, Christopher; Johns, Dawn Freshwater (Eds.) (2006). Transforming Nursing Through Reflective Practice, Oxford: Blackwell Publishing. Read More