Decision Making in Nursing Process

NB: We do not resell your papers. Upon ordering, we do an original paper exclusively for you.

NB: All your data is kept safe from the public.

Table of Contents

Introduction
The Nursing Process
Types of data
Implementation
Decision Making in Nursing
Conclusion
Reference List

Introduction

In the contemporary world, remaining healthy is a concern for every one of us. Therefore, there is a need to prevent all those aspects of nature that may lead to sickness in human beings. Hence, we find that many studies have been carried out by researchers and scientists to look into some of the efficient and effective ways of staying disease-free.

The Nursing Process

White (2005), states that the nursing process is a series of steps that lead to accomplishing a goal. The nursing process is a systematic process that is used in the provision of care to patients. This is mainly done so that each person can receive comprehensive and effective care efficiently. In the nursing process, the first step is assessment and involves the systematic collection, verification, organization, interpretation, and documentation of data. She argues that assessment is usually conducted so that the patient’s physical and emotional health status can be identified (Houser, 2008). When a patient visits a health centre, he or she is likely to have any of the following assessments: Comprehensive assessment that provides the client’s complete health history and current needs assessment. A comprehensive assessment is normally good if a nurse wants to determine the patient’s need for nursing care. Focused assessment is the second type of assessment given to patients (Tallberg & Paul, 1997).

They are usually used when short stays in the hospital are anticipated because the patient is not normally at risk regarding his or her health. The other type of assessment is the ongoing assessment which involves following up on problems discovered in the comprehensive and focused assessments. Therefore, this assessment involves systematic monitoring of specific problems and allows the nurse to validate the data obtained during the initial assessments and thus determine the individual’s response to nursing interventions and identify any other problems. In nursing, there is a wide range of sources used, but the patient is considered the primary source of data because a majority of information regarding any matter health wise comes from him or her. The other sources are classified as secondary because they come from other places and at times have to be verified to determine their accuracy (p.137).

Types of data

Ann-Marie & Beck (1996) says that during assessment two types of data is usually collected: Subjective and Objective data. Subjective data are viewed as the patients’ thoughts and concerns and this data is usually gathered during the interview with the patient. It also involves obtaining the person’s health status before the time the data is being collected (McConnell, 1993). Objective data are empirical. I.e. they can be observed and measured.

Once the data is obtained it has to be validated to ensure that there are no misunderstandings, omissions, inferences and conclusions. This is especially crucial because they can be used in the future when the patients come back to the hospital exhibiting similar illnesses.

Once the data is validated it is organized into clusters- a process of putting data together to identify areas of the client’s problems and strengths.

Data interpretation follows where nurses develop inferences on what the data collected means. When data is organized in clusters it helps the nurse know how the patient responded and in what pattern. The data is then documented depending on how the results came out. Data that shows some variations from the normal, for example, high fever and difficulty in breathing need to be reported to the doctor and recorded quickly. However, others are just recorded and no other step is taken prescribing a medication to relieve a headache.

Diagnosis

Beck (1996) argues that as soon as a client has been assessed the nurse goes a step further and breaks the data into parts so that data can be put together in a new way. The nurse has to understand the data well to help him or her to make an informed decision in developing nursing diagnoses. When analyzing the data collected the nurse has to make a diagnosis in any of the following three categories.

An actual nursing diagnosis is composed of a diagnostic label, related factors, and signs and symptoms because it indicates the existence of a problem. This can be used to diagnose situational low self-esteem.
A risk nursing diagnosis shows there is a potential problem. It begins with the phrase ‘risk for’ followed by a diagnostic label and a list of the risk factors (Thomson & Dawn, 2002).
A well nursing diagnosis is used to indicate the patient’s wish to get well. It starts with the phrase ‘readiness for enhanced’ followed by a diagnostic label (p.15).

Planning and outcome identification

According to Christine (2007), this process entails establishing guidelines for the intended course of action to resolve the nursing diagnoses and coming up with a plan to improve patient care. It occurs in three phases; namely initial, ongoing, and discharge. Initial planning entails the development of a preliminary plan of care by the nurse who does the admission, assessment and gathers comprehensive admission assessment data (White, 2005). Ongoing planning updates the client’s plan of care. In this phase the patient’s any new information about the patient is collected and analyzed. Discharge planning takes into account the needs of a patient after discharge from the hospital (p. 12).

Implementation

Leon & Sharyn 2009), argues that at this stage the nursing intervention identified at the planning stage are implemented as well as the delegation of nursing intervention tasks to other members of staff. During this stage, psychomotor and cognitive skills are essential to carry out the nursing interventions. Moreover, there is the documentation and reporting of data. The recorded data shows the clients condition prior to intervention, the specific interventions carried out, and the patient’s response to these interventions.

Evaluation

Charles (1993) argues that during evaluation there are attempts to find out if the patient’s goals have been achieved or not. Should the goal be met, then the nurse can decide whether nursing interventions should go on or otherwise. The success in this stage depends heavily on the other stages. That is, it is affected by the other components of the nursing process (p.121).

Decision Making in Nursing

Having gone through the nursing process it is time for nurses to make decisions. The accuracy of the decisions they make will depend entirely on the data accuracy too. Although the data collected might be correct, well documented and interpreted, the decision-making process might be affected if the nurse is not competent. Beck (1996) argues that clinical experience affects decision-making ability and hence prior experience with specific clinical issues is essential to enhance decision making (p. 208). Additional proficiencies in both clinical performance and decision making helps in developing a competency-based orientation program orchestrated by an expert preceptor.

According to Carl (2002), stress has also been found to affect decision making no matter how good data obtained was. Stress can come in a way of noise from equipment, anxiety, personality, and exhaustion. Stress can increase the rate of error making because the nurse mind is disturbed and hence affects his or her thinking. (p. 71). Decision making is central to professional nursing because it has important links to patient care outcomes.

Fugate (2010) argues that the other factors that can affect the decision made by the nurse are the social demographic of the patient and also the age, sex, race, religion and socioeconomic status of an individual (P.103)

For a long time, researchers have investigated the process, types, and quality of clinical decision making. The conclusion was that nurses with better communication skills had a greater frequency of actual decision making. Other researchers have looked at other approaches for example the informatics or algorithms to assist in decision making. Their verdict was that nurses who used algorithms used more thorough patient assessment and a more informed nursing response which enhanced patient management.

According to Walton (2007), a study in the United Kingdom revealed that nurses having college education were far much ahead in decision making than their colleagues educated in diploma programs (p.23). Booyens (2007), states with the advancement in technology, the aspect of decision making has been studied using computer assisted simulations whereby the nurses are required to make their decisions in controlled clinical situations. This is meant to improve their critical analysis of the data they get from their patients (p.26).

White (2005), argues that when patients visit various hospitals, the nurses do open a medical record file for them so that all the data obtained from them is stored there to avoid putting mixing it with the records of other patients. The file has a face sheet where the patient’s name is written, contact address, place of birth, sex, and marital status. There is also on the face sheet the time and date when the patient was admitted and the type of admission.

There is also the medical history of the patient where the past illnesses are looked at as well as their family history. The physician doing the assessment records the findings here. The data obtained from the interview with the patient is recorded in a nursing admission assessment which is also a part of the medical record file. The other information in this medical record file includes the physician’s report, consultation reports, laboratory reports, nursing discharge summary and advance directives (p.139).

Conclusion

From the above discussion, it is clearly shown that decisions about health care should be based on the best available data. This data needs to be of sufficient quality to be fit for its purpose and the data collected should not be biased (Geoffrey & Paul, 2003). The systematic reviews, in which the relevant research is sought, appraised, and summarized, should ensure that the necessary evidence is available to help the people concerned make informed decisions (Polit, 2009). A positive outcome for patients is the paramount goal of the nurses and therefore everything possible should be done to meet this target.

The government on the other hand should improve the working conditions of the nurses by giving them a good salary which can motivate them to work even harder and take care of the patients in a humane manner.

Reference List

Ann-Marie, R. & Beck, E. (1996). Decision making in nursing. New York: Delmar Publishers.

Booyens, S. W. (2007). Dimensions of Nursing Management. Lansdowne: Juta and Company Ltd.

Fugate, S. & Lucy, B. L. (2010). Foundations of Clinical Nurse Specialist Practice. New York: Springer Publishing Company.

Geoffrey, H. & Paul, W. (2003). Expanding the role of the nurse: the scope of Professional Practice. Oxford: Black well publishing Company.

Houser, J. (2008). Nursing Research: reading, using, and creating evidence. Maryland: Jones & Bartlett Learning.

Leon, K. S & Sharyn J. (2009). Community health nursing: caring for the public’s health. Ontario: Jones and Bartlett Publishers.

McConnell, C. R. (1993). Professional nursing management. Maryland: Jones & Bartlett Learning,

Tallberg, G. U. & Paul, W. (1997). Nursing informatics: the impact of nursing knowledge On health care informatics. Amsterdam: IOS Press.

Thomson, C. & Dawn, D. (2002). Clinical decision making and judgment in nursing. California: Harcourt Publishers Ltd.

Polit, C. B. (2009). Essentials of Nursing Research. New York: Lippincott Williams & Wilkins.

Walton, C. & Brenda, H. R. (2007). Reviewing research evidence for nursing practice: Systematic reviews. Oxford: Black well Publishing Ltd.

White, L. (2005). Foundations of Nursing. New York: Cengage Learning.

Click Here To Order Now!