Introduction
This chapter is about making decisions in practice, which is an integral part of care delivery. Indeed, as Thompson (2003) states:
It is clinical decisions that commit scarce resources to patients, determine the clinical outcomes associated with care, and, in part, shape the health care experience for patients and professionals alike.
This chapter focuses on making clinical decisions associated with care, as opposed to making financial or staffing decisions, as these are the first type of decisions that you will become involved with as a student nurse. Nurses are responsible for their decisions at a professional level; the Nursing and Midwifery Council make this clear in the ‘NMC Code of professional conduct’ (NMC 2008).
Every day of their working lives, health care practitioners make clinical decisions about patients’ health and well-being. These decisions may be taken at several different points in a patient’s care. Some decisions are made during initial assessment of a patient, and others are made in response to changes in their condition, which may occur over time or may occur very quickly. Indeed, research has shown that nurses on an Australian intensive care unit make one decision every 30 seconds! (Bucknall 2000). Having to make such decisions may seem quite threatening, yet you are actually quite experienced in making decisions, you may just not have thought about it before.
In your personal life, you are making decisions all the time. Some of these decisions you take on your own and others you make after consulting one or more people, but all require some background information about the issue in question. For example, if you are deciding whether to catch a bus or to walk to work, you need to know the bus routes, timetable and fares. You also require information based on your experience, such as how long it will take you to walk that distance, and you need information based on the current situation, such as ‘it is raining at the moment’. You need to be able to think about all the relevant pieces of information and draw them together to make your decision. This is also true of making clinical decisions. To make effective decisions about patients’ care you need to acquire sound background knowledge and develop good decision-making skills. These are sophisticated skills and you will need practice to enable you to become an experienced and confident decision-maker.
Evidence-based practice
The emphasis in health care today is on evidence-based practice. In 1998, clinical governance was initiated in the UK government’s white paper ‘A first class service: quality in the new NHS (Department of Health 1998). This initiative aimed to put clinical quality at the heart of trusts’ agendas, and included expectations of continuing quality improvement focused on clinical services and ef-fective use of evidenced-based practice. UK trusts are audited by the Healthcare Commission from which reports for each trust that has been aud-ited can be obtained (www.healthcarecommission.org.uk).
So what is evidence-based practice?Muir Gray (1997) stated that evidence-based practice is:
An approach to decision-making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits the patient best.
This means that decisions taken by health care practitioners for each individual patient are supported by the best evidence currently available, not just on experience or their own personal feelings. Indeed, McKibbon (1998) suggests that evidence-based practice is the formalization of the care process that the best clinicians have practised for generations. However, you will be aware of the so-called ‘postcode lottery’ in the UK, in which the type of treatment available for a particular condition varies depending on where you live. Evidence-based practice should reduce this effect, as everyone should be using the same evidence to support their care. It should also ensure that the latest research evidence about a topic is incorporated into the treatment of the patient. This is problematic though, as we cannot just accept a research paper at face value. You need to be able to evaluate research findings in order to determine the degree of confidence you have in the results of the research and the conclusions drawn by the researchers. Your training will include learning how to evaluate research evidence, and you can keep up-to-date with research relevant to your practice in a variety of ways. Sources of evidence-based information are given in Box 12.1.
Box 12.1
Sources of evidence for use in nursing practice (all accessed July 2006)
Bandolier (journal), evidence-based thinking about health care: www.jr2.ox.ac.uk
Centre for Evidence Based Nursing: www.york.ac.uk
The Cochrane Library: www.cochrane.co.uk
Database of Abstracts of Reviews of Effectiveness (DARE), The NHS Centre for Reviews and Dissemination, UK: www.york.ac.uk
Evidence-based Healthcare & Public Health (journal): www.harcourt-international.com
Journal of Evidence-based Medicine: www.bmjjournals.com
Journal of Evidence-based Nursing: www.bmjjournals.com
National Institute for Health and Clinical Excellence (NICE): www.nice.org.uk
RCN Clinical Guidelines: www.rcn.org.uk
Scottish Intercollegiate Guidelines Network (SIGN): www.sign.ac.uk
Wales Centre for Evidence Based Care: A Collaborating Centre of the Joanna Briggs Institute (JBI): www.cardiff.ac.uk
One source of relevant information is the Cochrane Library of Systematic Reviews. Each review evaluates research related to a particular topic and gives a recommendation as to the reliability and usefulness of the data. This means that the evaluation is carried out by experts so you don’t have to evaluate the data for yourself. For example, should colloid solutions (which contain particles that remain in the bloodstream) or crystalloid solutions (which readily cross cell membranes) be given to reduce the risk of death due to blood loss in healthy adults?Roberts et al (2004) reviewed the research in this area and concluded there was no evidence to support one solution being superior to the other, so which solution to use is still a matter for debate.
If you find some interesting research that you think may help your patients you must never, ever act on it by yourself. Discuss the article with your mentor or senior nurse. If they think it is useful they will discuss it with everyone at a team meeting and decide what action, if any, they will take. As mentioned before, your training will include learning how to evaluate evidence but it will be a long while before you can implement research findings yourself.
Decision-making
Bucknall (2003) observed that nurses feel more comfortable and look more confident making clinical decisions when they make decisions regularly and are able to compare situations either mentally or with colleagues. So what does decision-making involve? It has been described as:
A process by which a person, or group of people… identifies a choice or judgement to be made, gathers and evaluates information about alternatives and selects from among the alternatives.
Matterson & Hawkins (1990) further suggest that a decision ‘ends doubt and debate and occurs when the solution to a problem is uncertain’. This latter issue is very important. If a particular problem has a specific solution, there is no need for anyone to make a decision about the action to be taken. So how do you think in a structured way about making a decision?Carroll & Johnson (1990) suggested a model of decision-making that comprises seven stages. These stages do not need to be followed one after another, but each stage can be returned to as long as the stage is helpful in assisting the practitioner to make a decision. The seven stages are:
• Recognizing the situation.
• Forming an explanation.
• Forming alternative explanations.
• Searching for information/evidence to clarify each explanation.
• Making a choice between possible explanations, i.e. making a decision.
• Acting on the decision.
• Obtaining feedback to check the effectiveness of the decision.
We will look at these stages in more depth later in the chapter.
The nursing process
Making decisions may be easier if you have a framework or guidelines for making them. Frameworks and guidelines also ensure that each patient is treated similarly and important aspects of their care are not overlooked. These frameworks and guidelines are not used in isolation, however, but are commonly used within a cyclical problem-solving procedure described as the ‘nursing process’ (see Figure 12.1). This process was developed in the 1970s and was quickly adopted by nurses worldwide (Habermann & Uys 2005). Briefly, the cycle is as follows.
 |
| Figure 12.1The nursing process. |
Assessing
This describes the way you consider all of a patient’s individual needs. This holistic assessment should identify the patient’s physical, psychological, emotional, social and spiritual needs. This is the stage when you can use a model of assessment to collect relevant information, enabling you to make appropriate decisions about the patient’s plan of care (using models of assessment is discussed later in the chapter).
Planning
This is the stage of the process when you, in conjunction with the patient and, if appropriate, their carers, set realistic goals and plan how they can best be achieved. In common with goal-setting in other professions and situations, the goals set should be SMART (i.e. Specific, Measurable, Achievable, Realistic and Time-limited).
• Specific. The goals may be short term (e.g. nothing by mouth prior to a patient having surgery) or long term (e.g. enable a client with a learning disability to prepare and cook their own food).
• Measurable. Goals need to be measurable, otherwise you will not be able to evaluate whether the goals have been met or how effective the interventions have been towards achieving the goals.
• Achievable and realistic. It is vital that you recognize the patient’s individual needs and set goals that are achievable and realistic, so as to avoid disappointment if a goal is not achieved. You should encourage patients to participate in setting their own goals as everyone views their condition differently. A newly diagnosed diabetic, for example, might want to take immediate control of their care, whereas others might need a little time to take on this new role.
• Time-limited. It is important to determine a time period within which the goals should be achieved so that the patient’s progress can be evaluated.
Once the goals for the patient have been identified, you need to determine what activities need to be done, when they should be carried out, and who will be doing them to enable the patient to achieve these goals. You write this information into a care plan, which aids communication be-tween all members of the multidisciplinary team concerned with the patient’s care. But it is important to remember that primarily you are writing the plan for the patient and their carers and they are entitled to read them (discussed later in the chapter, under Record-keeping). So you need to write the care plan in a clear and explicit way that the patient can understand. It should give the patient a clear picture of the stages of the care, which may encourage them to participate in the plan. The plan must give very clear instructions as to who is to do what and when. Here are a few examples:
• The mother will feed the baby, using prepared bottles of milk, every 3 hours.
• The client will get up each morning at 7.30 a.m., wash and dress themselves before breakfast at 8.30 a.m.
• The health care assistant will help with personal hygiene needs until the patient is able to do it unaided.
Many clinical areas use integrated care pathways (ICPs). Each ICP is based on evidence and best practice and describes the plan of care that should be given to a patient with a specific condition (e.g. those who have chronic heart failure, or schizophrenia, or are undergoing knee replacement surgery). ICPs are followed by all members of the multidisciplinary team and so reduce the complications of different parts of the care being recorded on discrete notes that are kept separately. It also enhances greater understanding within the multidisciplinary team, enabling them to deliver an agreed plan of care for the patient as everyone is aware of what other professionals are doing. The patient also benefits from this by having a total picture of their care.
However, if you are using an ICP, you need to be aware that all patients are individuals and may have particular needs in addition to the needs identified through the ICP for their main condition. You need to record these individual needs and the associated goals in the ICP to make sure these additional needs are not overlooked. ICPs are explored in more detail in Chapter 13.
Implementing
This is the stage where you, the patient, their carers and other members of the multidisciplinary team, as appropriate, follow the care plan or ICP. You must ensure relevant interventions are carried out to enable the patient to achieve their goals.
Evaluating
This is the most important step of the process as it informs the patient, their carer(s) and the multidisciplinary team whether goals have been achieved or are being achieved. Your evaluation should determine future action. You may be noting success and stating that no further action is required or reassessing the situation and planning new goals, which takes you back to the beginning of the process. It is thus important that you set achievable goals so that the patient will be encouraged rather than discouraged. For example, it is possible to set short positive goals to note progress rather than regression; for example, a terminally ill patient in pain may have a goal of being pain-free for 1 hour, whereas a patient with chronic arthritis may have a goal of being pain-free for 6 hours. Setting measurable goals in the initial care plan helps you to evaluate your patient’s progress more effectively.
Using models of assessment
Many of your practice settings will be using a model of assessment. However, this may not be immediately recognizable as the team may have taken one of the known models and adapted it to be more appropriate for patients with conditions that they typically nurse. Your responsibility in each practice setting is to identify whether a model is being used, and, if so, to determine which one and to learn about it to enable you to deliver care in the same way as the rest of the team. This section does not describe all the nursing models available but highlights five that are representative of different ways to approach the decision-making process.
Biomedical model of care
This is the traditional model of practice, which has influenced nursing and medicine for a long period. There is a great deal of evidence to suggest that many nurses and doctors base their practice on this model, and many medical schools use the concepts within the model in the preparation of doctors (Pearson et al 2005). Hence, it is important that you have an insight into this model of care.
Nursing models are based on the following three components, which makes it easier to compare them:
• Beliefs and values.
• Goals of care.
• Knowledge required to achieve the outcomes.
The beliefs and values of the biomedical model are that humans are made up of biological components. Specialized cells make up tissues that comprise organs, such as the heart, liver and lungs. Groups of organs are linked together as systems, such as the digestive system, and all the systems interact together to achieve a balance, termed ‘homeostasis’. An imbalance is regarded as ‘disease’ with little or no consideration being given to psychosocial issues. Yet it is known that these issues can have significant effects on patients’ well-being; for example, stress can lead to an increase in colds and flu, irritable bowel syndrome, circulatory disorders, anxiety and depression. The goals of the biomedical model of care are to cure or treat the imbalance to restore homeostasis. Decisions regarding care are based on knowledge from biological subjects, such as anatomy and physiology, biochemistry, microbiology, pathology and pharmacology.
This type of model works well with traditional physical care and has a long history of success, but it makes no allowances for the individuality of the person. Indeed, critics of this model dislike the fact that it reduces a person to a set of parts that can be repaired or replaced, much like a machine. Recently, this model has been extended into the biocultural model of care (Morris 2000), which is based on scientific knowledge of human biology but also encompasses culture, thus recognizing that each patient’s beliefs, values and experiences influence their health and well-being. Prior to this biocultural model being proposed, some nurses, who recognized that their patients were all different, developed models to encompass the individual needs of their patients, including their psychological, social, behavioural and spiritual needs. Four of these models are described further.
Roper, Logan and Tierney model
This is probably the model most commonly used in the UK, particularly in adult nursing. It is based on a concept of nursing proposed by Henderson (1966):
The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge, and to do this in such a way as to help him to gain independence as rapidly as possible.
Henderson suggested 14 ‘activities of daily living’ and, from these, Roper et al (1980) developed the 12 activities which ‘people engage in to live’. Since its inception, these authors have continued to refine the model, the most recent version being published in 2000 (Roper et al., 1996 and Roper et al., 2000). The activities are listed in Box 12.2.
Box 12.2
The 12 activities which ‘people engage in to live’
• Maintaining a safe environment
• Communicating
• Breathing
• Eating and drinking
• Eliminating
• Personal cleansing and dressing
• Controlling body temperature
• Mobilizing
• Working and playing
• Expressing sexuality
• Sleeping
• Dying
These activities of living are then set against a lifespan continuum where conception through childhood and adulthood to death is aligned to a continuum from total dependency to independence and possibly to some level of dependency. When you assess a patient’s needs, the activities of living can be plotted on the continuum, enabling you to identify the stage of the continuum to which they are trying to return. For example, if a patient who eliminates independently has a temporary colostomy formed to aid recovery from major bowel surgery, they will be dependent for care of the colostomy until taught how to care for it themselves. In the long term, they will be fully independent again when the colostomy is reversed to enable normal bowel actions to resume.
The goals of the model are to enable patients to have maximum independence for the 12 activities of living, using medically prescribed treatments to overcome illness or its symptoms. In addition to the lifespan continuum, each activity of living may be influenced by biological, psychological, sociocultural, environmental and politicoeconomic factors. A patient’s health, therefore, will be influenced by a unique set of factors, which will be reflected in their living patterns. To help a patient to achieve the goals of the model, you need to know about their living patterns and the role each of these influencing factors plays in their lives.
Case history 12.1 shows an assessment of a patient using the ‘activities of living model’.
Case history 12.1
Mrs Bartlet
Mrs Bartlet, aged 77 years, lives in a ‘granny annexe’ at her daughter’s home. She is admitted to the ward via the accident and emergency unit following a fall that morning. She is diagnosed with a fracture of the neck of her left femur.
Assessment using the 12 activities of living (Roper et al 1980) was as follows:
• Maintaining a safe environment. Mrs Bartlet fell on the stairs and will need a handrail fitted before discharge. Has lived alone safely since her husband died 4 years ago.
• Communication. Mrs Bartlet is able to explain how she fell. She wears glasses for reading and watching the television but not when moving around the house. She has no problems with hearing. Her body language shows that she is in discomfort from her injury. Mrs Bartlet is aware of the name of the ward to which she has been admitted.
• Breathing. Mrs Bartlet has no problems with her breathing. Her respiration rate is 20.
• Eating and drinking. Mrs Bartlet prepares her own breakfast and snack at lunchtime. She has her main meal with her daughter and her family at 6 p.m. She has a cup of tea with her breakfast, coffee at mid-morning and after lunch. A small cold drink is taken with her evening meal. At present she is nil by mouth in preparation for her operation.
• Eliminating. Mrs Bartlet normally has her bowels open once a day. She needs to get out of bed at least once during the night to pass urine but has no incontinence. At present she is unable to get out of bed and so will need to use a bedpan.
• Personal cleansing and dressing. Prior to her accident, Mrs Bartlet was self-caring. She has a shower every morning but admits that she preferred it when she could get into a bath. She will need assistance with this at present.
• Controlling body temperature. Mrs Bartlet says that she enjoys the central heating in her home and was appropriately dressed for the time of year. Temperature 36°C.
• Mobilizing. Mrs Bartlet is now immobile. Prior to this accident she says that, although a little slow, she is able to get around her home and, when her daughter takes her there, is able to walk around the shops. She uses no aids. Waterlow assessment will be undertaken to assess her risk of pressure sores.
• Working and playing. Mrs Bartlet has not worked since having her two children (55 and 53 years old). Her husband was an accountant. She has many hobbies including reading, television, attending church and spending time with her grandchildren.
• Expressing sexuality. Mrs Bartlet enjoys shopping for clothes. A local hairdresser comes to her house every 2 weeks to wash and dry her hair and cut it when necessary.
• Sleeping. Her normal pattern of sleep is 10.30 p.m. until 6 a.m. and she says she often has a little nap after lunch.
• Dying. Mrs Bartlet was able to discuss the risks of a general anaesthetic at her age, but said ‘I have had a good life’.
This example highlights how an elderly person can become dependent on carers following an accident but, despite her age, following successful surgery, she could return home and continue living almost independently. You may also notice that, although the activities of living cover a broad spectrum, other assessments and measurements will need to be undertaken (e.g. Waterlow risk assessment, temperature and respiration rate). From the assessment, the following actual problems can be identified:
• Pain
• Immobility
• Personal hygiene: needs help at present
• Elimination: needs help at present
• Eating and drinking: nil by mouth prior to surgery.
The potential problems for this lady are:
• Pressure sores from immobility
• Thrombosis from immobility
• Dehydration from surgery preparation.
Hence, from using a model, the nurse can obtain a clear picture of the patient and the patient’s needs and plan the appropriate care.
Once you have used the model to identify a patient’s needs, you need to decide on a plan of care that will address those needs and write it up as described previously (see the section on planning, above). However, one of the criticisms of this model is that, although it is a more holistic approach to assessment than the biomedical model, it may still concentrate on the physical aspects of care rather than on other areas. Murphy et al (2000) carried out a small research study in Ireland and found the model was unsuitable for psychiatric nursing. It was as a result of this type of criticism that a plethora of other models were developed.
Roy’s adaptation model of nursing
This model of nursing was described by Roy in the 1960s and has been used widely in the field of psychiatric nursing (Roy 1976, Andrews & Roy 1997). Roy suggests this model embraces client-centred nursing and requires professional accountability. The framework suggests that each person responds or adapts to changes, termed ‘stimuli’, within their body or in the surrounding environment. Everyone is an individual and the way each person reacts to the environment is central to this model. Rambo (1984) described these assumptions as follows:
• Each person, as an integrated whole, comprises biological, psychological and social parts, and interacts with the environment.
• People adapt to change from within their body or in the environment in order to maintain homeostasis.
• The stimuli to which people respond are of three types:
Focal. These are direct causes of the problem and may be either within their body or affecting the person at the time (e.g. a leg wound or bereavement).
Contextual. These are indirect causes within the body or in the environment that might result in a poor response to the focal stimulus; for example, malnutrition may prevent healing of a leg wound, poor social circumstances may make it more difficult for a person to cope with bereavement.
Residual. These are the person’s beliefs, attitudes and past learning that may influence their current response. For example, one woman might tolerate pain during childbirth because she accepts that it is part of the process, whereas another might believe labour in the 21st century should be pain-free and therefore will expect to be given analgesia.
Everyone is an individual and will therefore adapt to situations differently. Providing stimuli are within the coping adaptations of that person, the responses to the stimuli will be adaptive or positive and homeostasis will be maintained. If, however, the stimuli are too large, the responses made will not be adequate to maintain balance; this is known as maladaptive or negative. For example, following the loss of a job, one person might think of it as another opportunity in life, enabling them to adapt positively and cope well. Another person might find losing their job is beyond their coping capacity, and respond negatively with anger, sleeplessness and poor appetite.
Roy suggests that there are four adaptive modes used to respond to stimuli to maintain balance:
• Physiological. As the name suggests, this is associated with the structure and function of the body and in particular the standards and ranges that are regarded as normal with respect to oxygen and circulation, fluids and electrolytes, elimination, nutrition, exercise and rest, regulation of temperature, senses and endocrine activities.
• Self-concept. This focuses on the way a person perceives themselves. Self-concept can be divided into two parts: the physical self, and the personal self. The physical self is concerned with how people perceive themselves either physically or mentally; for example, does the person perceive themselves to be ugly because their surgery resulted in a large scar, or frightened because they have to have another operation? The personal self is concerned with maintaining personal standards, behaviours and morals; for example, does the person feel anxious because they cannot maintain their personal standards when confined to bed-rest?
• Role function. The focus here is on social integrity and the roles each person plays within society. These roles can be described at three levels (Rambo 1984): primary and predetermined (e.g. gender, age, race); secondary, mainly permanent and chosen (e.g. parent, carpenter, Member of Parliament); and tertiary, fairly minor and chosen (e.g. union representative or choral singer). Illness can impact on one or more of these roles, and often it is the impact on secondary roles that leads to maladaptation. For example, illness might cause a person to be anxious that they are having time off work or unable to care for their child.
• Interdependence. This focuses on social integrity and the ability to maintain a balance between independence and dependency on others. For example, an older person living alone may be independent in cooking meals for themselves but dependent on others for shopping and providing the food to be cooked.
A person must make positive adaptations to stimuli to remain healthy and this is dependent on having the ability and energy to do this. Illness occurs when the adaptations needed are too great for the individual to make a positive response. The goals for nursing in this model must therefore be to support the patient’s adaptation to these stimuli. This can be achieved by:
• Assessing behaviour in relation to the four adaptive modes: physiological, self-concept, role function and interdependence.
• Identifying focal, contextual and residual stimuli influencing responses.
• Drawing up a care plan that:
Identifies problems.
Sets achievable goals.
Selects appropriate interventions.
• Evaluating care.
Roy’s adaptation model is a useful framework to use for patients as it considers them as individuals within the larger environmental setting. Case history 12.2 illustrates an assessment using Roy’s adaptation model within the mental health branch of nursing.
Case history 12.2
Tom’s story
Tom is 35 years old, unmarried and lives in a housing association flat. He has been in contact with the mental health services since the age of 22, when he was diagnosed with schizophrenia. The community psychiatric nurse who administers injections of antipsychotic drugs every 3 weeks maintains his condition. Tom will not admit that he is ill but agrees to the medication.
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