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Essay: Making a simple nursing decision within a complex case

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This essay will focus on critically analysing a simple nursing decision affecting a complex case. Lilly will be at the core of the decision making process as the nursing decision that will be discussed is to insert a urinary catheter. The essay will assess the decision making process from a newly qualified nurse [NQN] perspective, therefore considering the transition process and the perhaps daunting task of autonomous decisions. Evidence supporting and opposing the decision will be examined, compared and contrasted, helping to cogitate any ethical and professional principles that may influence the decision. There will also be reflection upon the extent to which the decision is aligned to theory, exploring decision making models [DMM] with consideration to their appropriateness in decision making within practice. To conclude, there will be an evaluation of the decision making process and its outcome, with review on how DMM and evidence have been influential. In addition, implications for practice, with particular focus on NQNs’, will be considered.

Complex care is a term used to describe a case deemed as clinically complex within the healthcare industry. For example, a patient in the community, with multiple co-morbidities, an extensive list of medications and who is unable to self manage, may be viewed as a complex case. In contrast, a patient admitted into hospital with an acute onset but without social support may also be regarded as a complex case (Jeffs et al. 2013). Evidently, the term complex care can be elusive and should not be used as a generalisation to describe a certain ‘type’ of patient, but a term used to define a continuum of care after assessing a patient’s individual circumstances, including sociological, physiological and psychological factors (McGreevey 2011).

According to Figa et al. (2015), the ageing population and the prevalence of long term conditions is increasing the number of complex cases in healthcare. This emphasises the rising responsibility for healthcare professionals to address complex care needs appropriately, to maintain patient-centred care and quality of life. Shipee et al. (2012) recognises the need for a complex care model to help healthcare professionals withdraw away from disease-centred care and focus on patient-centred care. The conceptual framework for complex care, though unpublished, alerts healthcare professionals to the holistic needs of the patients by determining physiological, sociological and psychological elements (see Appendix A). With regards to Lilly, she is experiencing a variety of complexities: some of which include pain from her bone metastases and lymphedema, incontinence and community challenges such as family carers. The conceptual framework for complex care provides a methodical approach for the NQN to consider all of the complexities affecting Lilly (see Appendix B). Rankin and Regan (2004) suggest healthcare professionals who recognise and understand the depth and breadth of patients’ complexities will provide a more holistic, individualised care delivery. This is particularly significant within EoLC as the palliative treatment of patients acts as a litmus test for all of those working within the health and social care industry (Department of Health 2014).

The focus of this essay is the decision made by a newly trained nurse to catheterise Lilly. Heany (2011) highlights the fact that catheterisation is derived from a medical decision. However, as Lilly is being cared for in the community, her General Practitioner [GP] signed a consent form permitting the nurses to make the decision to catheterise Lilly, with consent, for a suitable reason. The NMC specifies nurses must form clinical decisions on the best available evidence representative of safe nursing practice (NMC 2015). However, Holland and Roberts (2013) recognise autonomous decision making, nonetheless essential, can be an extremely formidable prospect for a NQN as it involves moral, legal and ethical convolutions all of which they are now accountable for. This is also acknowledged by the Novice to Expert framework by Benner (1984), a context describing how decisions are made, which suggests nurses develop experiential knowledge over time. This seminal framework also defines newly trained nurses’ decision ethic as rule-governed, which could be viewed as inflexible and restricted.

For the purpose of this essay, two DMM will be discussed and applied to the decision making process to catheterise Lilly. The decision making process is usually one that is subliminal in nature; DMM, however, can help an individual deliberately analyse their decision making process – an essential practise in the nursing profession (Dowding et al 2011). Kahneman (2011) developed a theory that describes a contrast between two models of decision making: System 1 is described as automatic, instinctive decision making and System 2, a slower more deliberate decision making process. System 1 can be compared to the expert nurses in the Novice to Expert framework by Benner (1984), who are described as using intuition as their main form of decision making. It can, however, be argued that intuition is essentially subjective, therefore distrusting its reliability for decision making (Holland & Roberts 2013). An additional decision making model is James Rest’s Four-Component Model [FCM] (1986). This model seeks to make decision making of ethics a recognised process by focusing on four stages: moral sensitivity considering the possible harm and impact the decision could make; moral judgement contemplating ethics and eliminating possible strategies; moral motivation involving the prioritisation of the issue and finally moral action – the ability to justify the decision made (Robichaux 2016). This model is comparable to Kahneman’s System 2 model (2011) as the decisions are made with careful analytical thought processing. The System 2 model of Kahneman’s (2011) and the FCM (1986) will both be explored further within the decision making process to catheterise Lilly because, according to Benner (1984), newly trained nurses are more likely to be guided by rules and evidence, suggesting a slower, more analytical decision making process, rather than intuition – the focus of the System 1 model.

Farrington et al. (2013) suggest the management of urinary incontinence at the end of life is as important as pain and nausea control. The NQN therefore needs to consider all of the possible strategies to control Lilly’s urinary incontinence; this careful deliberation is reflective of Kahneman’s System 2 theory (2011) and Rest’s moral judgement component in the FCM (1986). A systematic review of EoLC primary sources regarding the management of urinary incontinence, discovered many viewed catheterisation as an appropriate intervention for EoLC to promote comfort, maintain skin integrity and to avoid painful position changes. An alternative intervention considered was the use of incontinence pads, however the benefits of this were not explored, suggesting it is unfavourable. Moreover, the primary sources reviewed did not cite any evidence supporting their statements implying they are based on author opinion and experience (Farrington et al. 2013). Information based on opinion is at the lowest level within the Hierarchy of Evidence prism, indicating a lack of validity (see Appendix C).

The review by Farrington et al. (2013) also noticed the lack of professional guidelines for the management of urinary incontinence at the end of life, particularly concerning the insertion of indwelling urinary catheters. However, Benner’s (1984) framework proposes newly trained nurses lack intuition and form decisions by following rules vigilantly, and with a lack of guidelines, the decision to catheterise may appear challenging for the NQN caring for Lilly. Nevertheless, the systematic review by Farrington et al (2013) also discovered that the decision to catheterise at the end of life primarily relied on patient preference. It is therefore imperative that the newly trained nurse engages with Lilly to ensure she is an equal partner in any decisions made about her as she has full capacity, thus liberating the “No decision about me, without me” principle encouraging shared decision making (Department of Heath 2012). It is imperative that the dated paternalistic nature of healthcare is avoided by ensuring the patient’s voice is heard to promote autonomy and humanised care (Lewenson & Truglio-Londrigan 2015).

Lilly feels happy with the suggestion of catheterisation and has given her consent, however it is the responsibility of the NQN to analyse the risks and benefits. The NMC code of conduct (2015) indicates nurses are accountable for their actions; the NQN must therefore consider and apply the ethical principles of Beauchamp and Childress (2001) throughout the decision making process. For example, non-maleficence advocates actively preventing harm, yet catheterisation could be viewed as harmful. Evidence such as the European Association of Urology Nurses (2012) evidence-based guidelines concerning catheterisation, confirms that long term catheterisation carries an elevated risk of developing a urinary tract infection [UTI] which can lead to serious complications. Furthermore, in a retrospective audit, examining the use of indwelling urinary catheters in EoLC, discovered that the insertion itself can be painful and distressing to a dying person. In addition, 6 out of the 64 patients in the audit experienced pain from the catheters, but for the majority urinary catheters were documented as free of complications, suggesting catheterisation is a subjective experience, thus reinforcing the patient-centred nursing principle (Farrington et al. 2014). Nonetheless, the validity of this audit is questionable as only a limited number of patients were studied, additionally the audit has not been cited by any other researchers, making its reliability questionable, though it can be considered that this may be due to the lack of research surrounding the topic.

The third component within the FCM (Rest 1986) is moral motivation. The moral motivation for the newly trained nurse is to put the health of the patient first, demonstrating patient-centred care, a key professional principle within the NMC code of conduct (2015). Lilly’s drop in mobility and development of urinary incontinence increases the likelihood of moisture damage and pressure ulcers (Beeckman et al. 2014). Catheterisation could prevent the risk of developing moisture damage, whereas incontinence pads, though a non-invasive technique, may encourage the development of moisture damage (Farrington et al. 2013). Furthermore, in regards to the complexity of Lilly’s situation, the use of incontinence pads will not protect Lilly’s dignity or prevent painful position changes. Therefore, by incorporating Rest’s FCM (1986) to the decision making process the NQN can reflect moral sensitivity by considering the potential harm the decision could make, incorporate moral motivation by prioritising the health of Lilly and thus act with beneficence to realise that the risks outweigh the benefits in regards to the use of incontinence pads.

Lilly has expressed concern and distress about her urinary incontinence; it is therefore essential to consider emotional needs, as well as physical, when assessing the situation. Evidence has shown urinary incontinence can be particularly distressing and can increase anxiety for the patients and their families, having a detrimental effect on patient dignity and quality of life (Farrington et al. 2013). Lilly is likely to find her incontinence upsetting, especially in front of her children. Incorporating factors such as emotional needs, family, dignity and physiological health within the decision making process can help provide individualised care (NMC 2015). Furthermore, the Royal College of Nursing (2012) guidelines consider catheterisation compassionate for EoLC, a principle of the 6Cs which should be displayed consistently throughout nursing care. Additionally, Lilly’s husband, John, is also struggling with the emotional and physical strain of caring for Lilly.

Catheterising Lilly could convey ethical utilitarianism, the theory suggesting an action is morally right if the result is more positive than negative for everyone involved (Wheeler 2013). For example, catheterisation carries a risk of UTIs but it could also prevent unnecessary bed changes, promote Lilly’s comfort and preserve her dignity, all of which are beneficial for both Lilly and John. Ethical utilitarianism allows the healthcare professional to ensure the risks of their actions are considered, therefore advocating accountability. This could also compare to the ethical sensitivity component within the FCM (1986) as the NQN has considered all of the possible consequences the decision could create.

By exploring the benefits and risks of catheterisation, integrating all the complexities of Lilly’s situation and patient preference, the NQN made the decision to catheterise Lilly, using an indwelling urinary catheter and aseptic technique. The newly trained nurse demonstrated the ethical principle beneficence by coming to the conclusion that the benefits outweighed the risks. The insertion of the urinary catheter has promoted Lilly’s comfort, dignity and ultimately her quality of life. Furthermore, by catheterising Lilly she is less physically dependent of her husband who now feels less emotionally and physically exhausted. This decision has therefore demonstrated individualised, holistic care by incorporating Lilly’s physical, psychological and sociological needs.

Applying Kahneman’s System 2 theory (2011) and Rests FCM (1986) to Lilly’s case has enabled the NQN to analyse the decision making process. This is significant because, Farrington et al. (2015) has similarly noticed the absence of certitude surrounding the topic of best practice for incontinence management at the end of life and therefore suggests healthcare professionals should frequently examine their decisions regarding incontinence management. Additionally, it is suggested that the outcomes of the decision should be made aware of, to ensure experiential choices are made in the future. On the other hand, it could be argued the DMM mentioned are not applicable to every decision making process in clinical practice. For example, a cardiac arrest which requires a fast automatic decision making process links to Kahneman’s System 1 theory (2011). Therefore, the appropriate decision making model should be selected depending on the patient’s situation, again highlighting the concept of individualised care (Standing 2014).

Benner’s Novice to Expert (1984) perspective may view the lack of professional guidelines surrounding urinary incontinence management at the end of life as an additional challenge for a NQN’s decision making process. However, Dowding et al. (2011) recognised the need for student nurses to use clinical practice experiences to develop their intuition, as well as abiding by rules and regulations; this suggests newly trained nurses may already incorporate experiential knowledge to their decision making process. Inversely, evidence exploring the role of nurses in the management of urinary incontinence at the end of life suggests many credit their knowledge to more experienced colleagues in practice (Farrington et al. 2015). Therefore, upon reflection for implications for future practice, the NQN caring for Lilly may have benefited from deliberating with a senior member of staff to help support their decision, thus providing the additional experiential knowledge that Benner (1984) suggests is lacking. Subsequently, effective communication between staff could promote effective decision making within future practice. Furthermore, the ambiguity surrounding the professional guidelines may be reaffirming the subjectivity of catheterisation and therefore the need to assess every patient individually (Farrington et al. 2014). For that reason, patient-centred care and patient preference is a key significance to apply to the decision making process within future practice.

To conclude, this essay has considered the task of making a simple nursing decision within a complex case, from a newly qualified nurse’s perspective. By exploring Lilly’s complexity, the newly qualified nurse was able to form the decision based on Lilly’s individual situation, encouraging patient-centred care. From a Benner (1984) perspective, the lack of professional guidelines surrounding the management of urinary incontinence at the end of life presented extra challenges for the newly trained nurse caring for Lilly. However, primary sources for EoLC suggested patient preference is the key element when considering catheterisation. The newly qualified nurse therefore reflected upon the Kahneman System 2 model (2011) and the Four Component Model (Rest 1986) by ethically analysing the possible decisions and their risks and benefits in regards to Lilly’s individual situation, but at the foremost promoted patient autonomy and shared decision making by ascertaining Lilly’s wishes as the highest priority. The use of seminal decision making models promotes the analysis and reflection of the decision making process and outcome, highlighting their significance within the healthcare industry.

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