This assignment will focus on a clinical decision I made in practice on

an acute medical ward as a second year nursing student. In order to

maintain the patients confidentiality I will be using the pseudonym
Lillian as the patients name. (The Nursing and Midwifery Council, NMC,
2015). Lillian was a 80 year old lady who was admitted to the ward due
to a urinary tract infection (UTI), (?it was noticed by myself other
nursing staff that Lillian had lack of mobility or that it had decreased
since having the UTI (which lead to decreased mobility and) the
decision to provide Lillian with pressure reliving equipment (PRE).
Theoretical models of decision making will be discussed and I will
explain how they aided in my overall process of decision making. The
reliability of knowledge and assessment data will be evaluated and the
impact this had on my decision will be highlighted. The importance of
effective communication will be outlined and the professional
obligations a health care professional (HCP) must adhere to in order to
maintain patient autonomy and provide person centred care will be
discussed. Explain that why your doing this essay? Give scope etc.

Clinical decision making is carried out by nurses routinely during

practice. It involves combining theory to practice situations in order to
reach a decision regarding a patients care (Standing, 2011). There are
a number of decision models available to aid in making clinical
decisions and I used the descriptive theory which is process orientated
in(in? maybe by?, just sounded odd but might be right) nature
(Gurbutt, 2006). It also focuses on how a clinician will use their
professional judgement when making decisions related to care
(Thompson and Dowding, 2009). I used the hypothetico-deductive
theory which has four different stages (either say in brackets what the
four stages are, or appendix or if your essay senario says that/covered
it in uni then thats fine. but me as a reader i have no idea what THEY
are) (EDIT: i see you write what they are later, maybe you could write
them here tho aswell?) and is one of the descriptive theory models
(Thompson and Dowding, 2009).

I met Lillian when she arrived on the ward from accident and
emergency department. I was given a hand over by another member
of staff allowing me to obtain Lillians diagnosis and clinical information
via her medical notes, and with doing this at this I had already begun
using the hypothetico- deductive theorys first stage, cue acquisition
(Thompson and Dowding, 2009). It has been identified by the National
Institute for Health and Care Excellence (NICE) (2014) that those with
limited mobility, like Lillian, can be at high risk of developing a
pressure ulcer (PU) as they may be unable to change their position as
often as recommended in order to prevent PUs from developing. Being

aware of this information and also seeing the occurrence of PUs in

patients less mobile from previous practice experiences, I generated a
hypothesis (Thompson and Dowding, 2009) (is this the second stage?)
and recognised Lillians skin integrity could be at risk. In order to
assess my hypothesis I needed to gather more information by
completing a waterlow assessment, a tool used by HCPs to indicate
the possibility of patients developing PU in their current medical
condition. The tool is recognised as creditable and recommended for
use by NICE (2014).

The waterlow assessment contains several different sections, one of

which describes the patients skin type and visual risk areas. In order
to complete the assessment correctly it was necessary to examine
Lillians skin and therefore consent needed to be gained (NMC, 2015).
In this instance Lillian was found to have mental capacity (maybe say
that lillian has been assess and has no mental capacity issues or
soemthing, cos it sounds like you have assessed) and therefore once
provided with information as to why I wanted to complete the
examination, could make an informed decision and provide informed
consent (Gallagher and Hodge, 2012). As Lilians skin was exposed it
was crucial to ensure her dignity was maintained, and for this reason
the curtains were pulled around her bed for privacy and dignity. (NMC,
2015)

After completing Lilians body's skin check (review? assessment? not

check.) I could accumulate a score to ascertain if she was at risk.
Although I did not find any PU (in) on her common pressure areas ,
Lilian had a water low score of 18 which put her into the category of
high risk, which is a score of 15-19 (REF). As I used a risk assessment
to gather more information in relation to my patients condition I had
now reached the cue interpretation phase of the hypotheticodeductive model. I used this evidence to understand if the results
coincided with my initial hypothesis, and in this instance it could be
seen that the hypothesis and interpretation matched, and I had thus
completed the last stage, hypothesis evaluation and decided on an
appropriate intervention for Lillian (Thompson and Dowding, 2009). At
this point if my hypothesis did not match the hypothetico-deductive
theory would be repeated from the start until I had reach a accurate
decision/judgement (such as? remember to always relate your
theroy's/models to the patient senario to get the marks (Thompson and
Dowding, 2009).

Although the waterlow assessment is recommended for use by NICE

(2014), there are many whom believe the tool is subjective and
therefore my result may be different to that of another HCP (Nazzarko,
2009; Walsh and Dempsey, 2011). It is also criticised as it can cause
over prediction of the risk of a patient developing a PU (Narako, 2009
and Walsh and Dempsey, 2011). This can lead to patients having
equipment which is not necessary which endures significant costs for
the National Health Service (Aston et al, 2010). For these reasons the
waterlow tools validity and reliability could be questioned when using it
to aid in making a decision. However by ensuring I had competence
and confidence in my abilities to complete the waterlow assessment
correctly I helped to make my score as reliable as possible (NMC,
2015). My mentor also reviewed my assessment and agreed with my
score of 18, this is an important part of my decision as all
documentation and risk assessment tools I complete must be counter
signed by a registered nurse. My mentor agreed with my decision and
also believed it would be in Lillians best interests to be supplied with
pressure reliving equipment.

I believe I used a systematic approach to reach this decision which

Standing, (2011) explains is often used by nursing students when
making decision and involves using critical thinking alongside problem
solving. The nursing process model explains this approach guides HCP
to assess the needs of their patients and plan and apply appropriate
interventions (Yura and Walsh, 1973 cited in Standing, 2011). As I used
a risk assessment tool to aid in my decision making process I used a
statistical approach which is recognised by Thompson (2002, cited in
Standing, 2010) as a component of the normative theory which
presumes the decision maker is rational and logical. Pritchard (2006)
states normative theory and the systematic approach are intertwined
due to use of guidelines, this allowed me to provide an intervention for
Lillian which is evidence based.

It is believed by Benner (1984, cited in Standing, 2010) that knowledge

plays a part in nurses being able to make reliable clinical decisions and
highlights this in his stages of skill acquisition model novice to expert,
and believes experience and intuition are also drawn upon to aid
decision making. It is thought the reason experts are able to make
reliable decisions is due to their extensive knowledge (Thompson and
Dowding, 2002). However as I was a second year student when making
this decision Standing (2011) recognises there would have been gaps
in my clinical knowledge and understands, this is due to me being only
an advanced beginner on Benners (1984, cited in Standing, 2010)
model and for these reasons I will use my mentor who is an expert in

their field to gain knowledge and help develop my decision making

competencies. However it can be argued that the hypotheticodeductive theory needs a certain amount of knowledge in order to
generate a hypothesis. Dowding and Thompson (2002) explain intuitive
decisions do not use rational, for this reason Standing (2010) suggests
professional accountability could be compromised as no analysis or
evaluation took place when making the decision consequently when
asked how the intervention was decided they cannot always answer as
intuition can be described as a sixth sense (Standing, 2011). Hence
someone with limited experience such as myself would not usually use
intuition to guide clinical decisions and would opt for the hypotheticodeductive- reasoning instead, and more experienced clinicians such as
my mentor may use intuition alone (Dowding, 2009).

Thompson and Dowding (2009) believe HCPs can become

overconfident in their knowledge and its correctness, leading them to
taking cognitive shortcuts known as heuristics. A form of heuristics is
anchoring, where judgements are made from first impressions thus
bias and prejudices are formed (Thompson and Dowding, 2009). As my
decision involved using evidence based practice this rules out any bias
which can be encountered when the HCP uses intuition alone (Rajkmor
and Dhaliwal, 2011). Another weakness of using intuition and
knowledge could be its reliability due to the overestimation of
correctness previously mentioned. Eva (2005) supports this
assumption and believes using numerous theories together can
improve the accuracy of decisions. The normative theory has another
strength as it: helps minimizes judgement errors from base rate
neglect (Thompson 2002, cited in Standing, 2011). Short (2015)
states heuristics and base rate neglect can lead to stereotyping, as a
result discriminatory practice can arise something which is highlighted
by the NMC (2015) as not acceptable. Consequently the theories I used
to make my decision could be considered reliable and beneficial in
ensuring bias and prejudice do not occur.

Although I have explain how decision making theories can be used to

ensure effective decisions are made, I need to be aware how I present
this information to Lillian could sway her into choosing a intervention
which I believe is in her patients best interests, this process is known
as nudging and comes under the concept of choice archiculture (Thaler
and Sunstein, 2008). As my intervention is not very complex in nature,
I gave Lillian the choice to either have the PRE or to decline, however if
the situation was more complex and involved several care options, this
is when the process of nudging could readily occur. Although the code
of conduct states I have a duty of care to act in the best interests of

my patients, it also highlights the importance of respecting their rights

to decline treatment and thus their autonomy (NMC, 2015). Several
studies claim that the use of nudges in health care can lead to
undermining autonomy and liberty as the patient may have been
manipulated into making their decision (Boven, 2009 and White, 2011
cited in Quigley, 2014). Hence it could be implied using nudging does
not abide by professional standards (NMC, 2015) and takes away the
patients responsibility in decision-making (Quigley, 2014). Standing
(2011) believes this should not occur, as in order for me to provide
person-centre care Lillian and I must collaborate in decision making.
This is also supported by The Department of Healths, (2012)
publication, "No decision about me without me", (if thats the name of
the publication, use caps etc) which identified the importance of
patient empowerment. If I had used nudging with Lillian to gain her
consent to using PRE, I would have been acting in the principle of
beneficence (Gallagher and Hodge, 2012). Nonetheless it would have
been inappropriate for the above reasons. It should be recognised that
nudges have be successfully used by the government on a larger scale
to change unhealthy behaviours and promote health (Local
Government Association, 2013). Reach (2013) believes this is
acceptable, but would not be acceptable for me to use in the case of
an Individual such as Lillian. It is therefore important for me to have
good communication skills as underlined in NMC (2015), in order to
avoid the use of nudging in future practice situations.

Lillian consented to having PRE however if she had refused Gallagher

and Hodge (2012) suggest myself or my mentor using persuasion
would have been ethically acceptable, in order to prevent the
deterioration of her physical health. It should be highlighted persuasion
if (is) different to coercion which involves threats to get patient to
agree to treatment which is ethically incorrect and would involve not
abiding by The Code of Conduct (NMC, 2015). Baillie (2009) explains
as Lillian is now using a pressure reliving air mattress her acceptability
of it is crucial, and if it causes her discomfort or pain the use of this
equipment should be reassess. NHS trust (2012) also states Lillians
waterlow should be reassessed weekly and her nutritional status
monitored. Consequently although the decision I made at the time was
correct it should be remembered Lillians need for the PRE could have
changed in the days to come.

This assignment has allowed me to critically reflect on a decision I

made in practice and I now have a deeper understanding of the
complex processes used to guide clinical decisions. It has highlighted
the potential errors which can occur if I were to use intuition alone

when making a decision, and subsequently the importance of gaining

as much knowledge as possible whilst on future placements from my
mentor and other HCPs. It has made me aware of the potential bias
and prejudice that can unintentionally arise in practice due to HCPs
first impressions.