Decision Making Process of Newly Qualified Nurse

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In order to understand the decision making process of newly qualified nurse (NQN) in the community setting, the purpose of this essay is to demonstrate the ability of the author to apply decision making models to a complex care scenario. There is discussion with relevant evidence in terms of using critical approach to make evidence-based decision. Decision making models will be discussed and critical analysis will be carried out and will illustrate the nurse’s role to deliver safe, therapeutic and holistic care.

Patients who have chronic illnesses with co-morbidities need complex care. The king Fund study showed that people with chronic illnesses are living longer due to increased knowledge of complex care within in the health professionals. The community NQN has decided to take a continence assessment on a patient in his own home. The case scenario and essay is using pseudonym to protect confidentiality and in line with regulations set by NMC code.

As defined by the Jeffs et al, complex care is when patients are required significant amount of care suitable to their associated needs for having number of co-morbidities or chronic illnesses. This can be deduced as people with complex needs requires substantial amount of support in terms of physically, intellectually, emotionally and spiritually by the theory of Sieben-Hein and Steinmiller. This theory incorporates a multidimensional approach to the understanding of the complex care. in complex circumstances, these fundamentals combinations are the ones that nurses acknowledge which helps them to meet the needs of the patient and provide quality care.

Newly Qualified Nurse (NQN) was asked to visit to Oliver’s and have his COPD check, with constant visits from the community nurses. The influence of COPD on Oliver’s body relates with the explanation implied by Bourdin et al, who state that there is severe obstruction in the pulmonary arteries. Patients like Oliver endure with damaged airways through an increase in mucus, instigating swelling and to a patient who has difficulty for breathing. Advanced COPD distresses the whole respiratory tract causing decrease in oxygen perfusion and increasing shortness of breath.

Barnes states that COPD can be significant co-morbidity of other health issues such as diabetes and depression, a theory reinforced with evidence by MacKay and Hurst. However, in Oliver case this could have been caused by his many years of smoking as this is also a known aid to the chronic illness. Oliver smokes around forty to fifty cigarettes daily. Smoking is one of the common factor to be known to contribute to lung diseases, blocked arteries and even further leading to cancer. 

As stated by the British Thoracic Society, that 50% of respiratory diseases are caused by smoking and is more likely to take part in cause of chronic illness such as COPD. It is essential however for the NQN to recognise why Oliver continues to smoke on a daily basis. It is apparent that people who suffer with multiple conditions have higher tendencies to smoke even after understanding the risks, it fronts on the body.

Oliver mobilises using a wheelchair since his car accident which resulted in bilateral amputations, the influence of this on Oliver’s health in huge. In addition to his chronic illness, he has two grade three pressure ulcers which are situated on his buttock and sacrum. Pressure ulcers happens when the patient is immobile, friction and shearing. Oliver has also stated that his daughters do his grocery shopping and that he barely mobilises in the house which explain the pressure ulcers. 

Pressure ulcers take place by the breaking down of skin which is caused by the decrease amount of blood flow in the area which leads to low level of oxygenated blood flowing through the surface of the skin. Oliver’s pressure ulcers are categorised as grade three because the affected skin area has full loss of dermis, allowing the presence of subcutaneous fat and slough to the wound bed. During the visit, NQN noticed that the pressure ulcers were further cast off from skin and was macerated and also probably soaked in urine which could be the cause of strong urine odour in the house.

Oliver is visited by the community nurses twice in a week. They visit him to assess and re-dress the wounds to avoid any further breakdown. Assessing and redressing pressure ulcers are very important because the poor wound assessment and management can lead to further complications such as infections.

Nurses are required to be competent in order to make clinical decision making (CDM) which are effective by using practice which are evidence based. Newly qualified nurses (NQN) is essential for them to understand the importance of CDM to achieve the best possible outcome and also to meet the needs of the patient with clear justification of their decision.

According to the NMC 2015, the patient’s involvement together with health care professionals including nurses is required when coming out with a decision for the well-being of the patient. Therefore, it is required for the NQN to also consider patient’s involvement and encourage for their input when making decisions so the care you are providing patient centred care. Nurses need be prepared to deliver self-directed and holistic care by certifying the reasoning behind the care and also be liable for their decisions.

The purpose of CDM is to have a positive influence on the patient health and well-being. CDM can have progressive impact on patient’s welfare by improving patient’s knowledge and information about their conditions. It is important for them to have knowledge and information about their condition as it makes it easier for them to comprehend the reason behind why healthcare professionals is making some decisions (Blum,2010). Rendering to the NMC 2015, occasionally it is necessary for patients to accept the decisions that been made my healthcare professionals which is made after MDT (Multiple Disciplinary Team) meetings. This is because healthcare professionals come to the decision looking at the progressive effect on patient’s health encompassing both physical and mental needs.

The CDM of the NQN is simple which it to undertake a continence assessment with Oliver. This decision can be supported because of his wounds being further moist and squashed and also being almost cast off from the skin when his wounds were being assessed. When making clinical decisions, the NQN requires to have the reason for the action made with supports such as the learning experience, familiarisation about the medical conditions and also the ability of nursing care. 

Carrying out a continence assessment with Oliver can raise ethical issues of consent. Therefore, informed consent should be in placed when making the decision with Oliver as ethical guidelines regarding consent is vital for the patient’s human rights, independency and also right respect patient’s decision if they don’t wish to consent. However, if the patients do not have the capacity to make the decision for themselves and it can be life threatening factor then nurses and other professionals can act upon to provide the care and treatment with the best interest of patient. So, Oliver having the capacity and understanding what the continence assessment involves makes the assessment within the guidelines.

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Outlining the importance regarding the Benner’s method to the decision making model ‘Novice to Expert’, the model suggests that nurses throughout their profession moves through five stages. Nurses steps through the stages by obtaining the complex knowledge of their position and experience grown within a responsibility and role as a nurse. NQN is generally reckoned as competent although lacking in terms of experience inside the field which is why they are known as the ‘advanced beginner’. 

Agreeing to the Blum, 2010, that is because a new setting can be quite intimidating for NQN and make them feel uncomfortable and also not knowing what to expect which may cause them to loose in confidence as before they had trainee role as a student nurse. As a student nurse you are described as a learner however when you are a qualified nurse, you are expected to have certain skills and competencies. The skills and competencies that NQN may not be able to display fully when they are placed in a new and unfamiliar setting. Though, Benner disputes that the skills, knowledge and experience of making efficient clinical decision without the contribution of other nurses is acquired in the clinical setting.

This is illustrated by the Oliver’s case as NQN during the trainee period, throughout the placements, the NQN have come across incontinent patients during the programme to become a registered nurse. NQN with their placements experience are able to understand the significance of addressing the matters that will affect the patient’s health while perpetuating the dignity of the patient. So, the NQN have the understanding of association between the urinary incontinence [UI] and the reduce in mobility, depression and constipation. This knowledge and skills which have been obtained throughout the experiences help the NQN to determine what decision will be made and will be effective with best interest to the patient.

The use of Benner’s theory expert to novice and the clinical nursing decision conveys to a model proposed by the Elstein et al known as the Hypothetical-Deductive Reasoning Model (HDR) effectively. The Elstein et al model, HDR has been renowned model which is used to help making final decisions. The first stage to take place in the model is cue acquisition where information about the patient is gathered. For this scenario, the information about the patient is the medical history of Oliver, medical notes from his general practitioners and also the information gathered from the NQN. This includes the observations that NQN took operating the National Early Warning Score (NEWS) 2 assessment tool when assessing Oliver.

According to the Elstein et al 1978, stage two of the HDR is when a collective hypothesis can be assembled considering Oliver’s care such as his substantial medical history and medical notes. With the help of the Oliver’s medical notes, it shows that he didn’t have any issues of UI. This indicates that the UI is new change in his health and should be essential for the NQN to question the cause and impact it may cause in Oliver’s health. CDM made by the NQN, continence assessment can be very crucial and understand the issue that may have cause the UI. NQN can make Oliver understand what the assessment is about like what you do and who are involved doing the assessment. This may eventually help Oliver ease and also be less embarrassed when knowing that only few people are taking part in the assessment.

Cue interpretation is the stage three of the model HDR. In this stage, the information that has been gathered in stage one and two are analysed, assessed and re-viewed. In the scenario of Oliver, his observations are stable is scoring zero in NEWS 2 score. Urinary tract infection (UTI) was ruled out for being the cause of the continence as his urine didn’t have offensive smell. However, the NQN considers that there are other factors such as past medical histories and co-morbidities which could be contributing to UI. Continence assessment can be quite embarrassing so, building a trust bond with Oliver can allow the him to be comfortable to discuss about embarrassing things. This shows that NQN respects and acknowledge Oliver’s feelings. 

As suggested in the HDR approach, interpretation and cue acquisition are the factors that contributes to CDM and also to induct conversation regarding the deterioration of pressure ulcers which can assist in collecting evidence. In relation to Oliver, this would include integrating a wound care assessment as a guideline to the best treatment, and also evidence around incontinence and wound deterioration. This will help Oliver recognise the reason why a CDM is put in place. The NQN uses the formerly obtained knowledge and assess along with the observation of the wounds and also to deliver the evidence of any hindrance that may come across in the process for healing of Oliver’s wound.

NQN may find it difficult to determine what is affecting Oliver as there are many roots to UI. This could be solved with developing trust between patient by communicating effectively and also reassuring the patient that the conversation and all the information about them are kept safe. This shows the weight of sustaining the privacy and dignity of Oliver. This is required to be consistent throughout his assessments and can only be shared with others by his consent or with other health professionals who needs the information for Oliver’s best interest.

According to the NHS England, continence services are valuable and primary part of the NHS in offering quality care to patient who experiences incontinence. To reduce urinary incidents that Oliver is facing, Package of care (POC) could be in place to help Oliver with his mobility and transferring around the house and also to the toilet. This will not only help him with his issues with continence but also benefit Oliver with his COPD (Chronic Obstructive Pulmonary Disease). 

Due to receiving care for his continence his pressure ulcers may have better healing process which will be beneficial to Oliver’s welfare. Therefore, it is necessity for the NQN to follow an evidence-based approach. Saxer et al contend that in turn for a community nurse to conduct a continence assessment, it is crucial for the NQN to have adequate knowledge and understanding of the assessment and also the weight of the CDM to provide the patient with full support and care. This shows exercising the Elstein et al HDR model with decision making, including Benner’s novice to expert approach as the best way to make a CDM with adequate amount of evidence considering the situation

This links clearly using Elstein et al HDR model within decision making, including Benner’s novice to expert approach as the best way to make a decision, and must include a sufficient amount of evidence regarding the situation before agreeing to proceed with the decision.

The final HDR process where the NQN assesses the situation, evaluating all pros and cons and certifying the most constructive and beneficial outcome is preferred for the patient. This further have impact on the decreasing the patient requiring medical attention and even hospitalisation by reducing the risk of any infection caused by pressure ulcers.

Health care services where reflection is practiced, the quality of care improves and also helps prompting the NQN’s personal and professional growth. So, practicing reflection is useful because it allows the NQNs to identify which aspects of their competencies and skills need to be enhanced. The NQN should always reflect and analyse critically about their actions and CDM they make. They should constantly work within the professional restrictions and being predisposed for their actions and future plans.

Conclusion

The evidence provided in this essay gives an insight of how making a clinical decision is a complex structure which are affected by many variables. Future for nursing has gotten shift from being typical nursing profession to a profession where critical thinking and also being able to challenge situations are found in nurses. The CDM of a NQN has been carefully contemplating and rationalised in regards to the complex case they face in practice. The scenario that been used throughout the essay has shown that the use of decision making models and evidence that emphasis the ability of the NQN in CDM. Through this essay, it is shown that CDM relies on personal and professional development of NQN through the novice to expert range alongside the use of the evidence-based practice.  

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