help due in 24 hours

C linical decision making encompasses a multitude of factors besides acting on a decision made (Tanner et al, 1987). It is as an ever-evolving process of evaluating gathered information, to enable the most appropriate course of action to take place

(Standing, 2014; Tiffen et al, 2014). The patient is the constant factor in the decision-making process and should be encouraged to contribute their thoughts and feelings about their care to enable shared decision making (Nursing and Midwifery Council (NMC), 2015).

John Rogers (anonymised to maintain confidentiality in accordance with the NMC (2015)) was being cared for by me and my mentor when he complained of sudden onset of acute chest pain. This is known as acute coronary syndrome (ACS), an umbrella term for a number of heart-related conditions stemming from chest pain (Bobadilla, 2016; National Institute for Health and Care Excellence (NICE), 2010).

In this article, the decisions taken during Mr Roger’s care will be examined and justified through the use of a systematic decision- making model, while referring to the necessity for collaborative decision making and self-reflection. Clinical evidence, such as clinical guidelines, will be critically analysed, ensuring that a clear rationale was reached before further care was implemented, and ensuring Mr Roger’s involvement throughout this process.

Influences Former Health Secretary Andrew Lansley coined the phrase ‘No decision about me, without me’, describing the influence patients should have on their care, and placing them at the centre of discussions with their health professional (Coulter and Collins, 2011; NHS England, 2016). This ethos of compassion and inclusion in practice is underpinned by the six Cs of nursing as supported within the Compassion in Practice strategy (NHS England, 2016). Shared decision making entails an evidence- based approach to building a treatment plan, placing the patient’s preferences at the forefront of care and is an ongoing, flexible process (Kasper et al, 2012; Capita Group, 2013).

Decision making has been discussed specifically in relation to angina. Patients with this condition maximise their quality of life by choosing treatment options best suited to their lifestyle

Decision making in practice: influences, management and reflection Neil Ellis

ABSTRACT During placements, student nurses encounter a multitude of scenarios where decisions are made that influence patient outcomes. Many factors help support these decisions and this article will use a number of theories and models to analyse a clinical decision. It will critically discuss what influences health professionals’ decision making and how they present treatment options to patients. The importance of reflection in decision making and its role in broadening students’ knowledge on key nursing skills and best practice techniques in preparation for registered practice are also discussed.

Key words: Clinical decision making ■ Chest pain ■ Acute coronary syndrome ■ Communication ■ Students ■ Patient preference

Neil Ellis, Final Year Student Nurse, University of Surrey, Faculty of Health & Medical Sciences, Guildford, [email protected]

Accepted for publication: January 2017

(Coulter and Collins, 2011). Fundamental to this process is informed consent, giving a patient such as Mr Rogers a choice to accept or refuse treatment when provided with information and potential outcomes (Aston et al, 2010; Coulter and Collins, 2011; NMC, 2015). This would also depend on the patient’s capacity to make decisions, as defined by the Mental Capacity Act 2005.

However, Mr Roger’s presentation of chest pain indicated one suitable option, supported by NICE guidance (2010), to gather further assessment information starting with an electrocardiogram (ECG). This was clearly documented in Mr Roger’s notes to facilitate continuity of care between multidisciplinary teams (MDTs), thereby ensuring that safe and appropriate care was initiated (NMC, 2015).

Furthermore, health professionals must be guided by non- maleficence, to do no harm, while encouraging good health and wellbeing through effective nurse-patient relationships (Sohn, 2013), which has being respectful, autonomous and fair at its core (NMC, 2009).

The ‘hypothetico-deductive’ model of clinical reasoning describes how health professionals make decisions (Elstein, and Schwartz, 2012). This is described as a systematic process where hypotheses are formed and challenged through analytical testing (Pelaccia et al, 2011). Standing (2014) supports this but argues that implementing first-class care, to alleviate suffering and promote good health and wellbeing, stems from a nurse’s ability to effectively exercise clinical judgement, assess potential alternatives and make informed choices.

Implementing effective care for Mr Rogers required gathering cues about his condition—shortness of breath and left-side radiating chest pain. Cue acquisition is the first step in

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Elstein’s 1978 model, a systematic approach to decision making triggered by key indicators (Tanner et al, 1987). The second stage is hypothesis generation, the formulation of a diagnosis based on the information available (Tanner et al, 1987; Pelaccia et al, 2011). Mr Rogers’ pain was indicative of cardiac pain and needed immediate attention.

I reported my hypothesis to my mentor and suggested that an ECG be completed immediately as I felt Mr. Rogers was suffering from a suspected episode of ACS. With the support of my mentor and guidelines for the assessment and management of suspected ACS, we were able to implement appropriate care to Mr Rogers. By asking relevant questions regarding Mr Rogers and the context of his care, as a nursing student, I was able to use my experience and knowledge to establish the same hypothesis as my mentor (Tanner et al, 1987).

Normative theory, the ‘ideal world’ answer to decision making, which takes a logical and systematic approach with expected outcomes, helped to rationalise my decision (Shaban, 2005). Using normative theory allowed for the systematic gathering of further assessment data from Mr Rogers and therefore led to the refinement of cues, as described by Shaban (2005). Mr Rogers’ symptoms indicated suspected ACS, therefore guidelines from NICE (2010) were followed and a normative approach was applied. However, the credibility of normative theory in practice has been disputed owing to its reductionist approach to decision making, where patient empowerment is excluded (Shaban, 2012). I ensured that my decision-making process involved Mr Rogers at all times.

Prescriptive theory was used to contextualise this decision. This is used to support our judgements by synthesising available information arising from guidelines such as NICE (2010) and clinical assessment tools such as the National Early Warning Score (NEWS) to ensure the correct choice was made in partnership with Mr Rogers (Royal College of Physicians, 2012; Shaban, 2005). The strength of prescriptive theory is that it allows for the best possible patient outcomes to be achieved as thorough assessments are completed and the information is used to form a rational conclusion (Shaban, 2005).

Communication between people is expressed not only through speech, but through the use of body language and facial expressions (Bach and Grant, 2015). The importance of understanding patient preferences for methods of communication, such as verbal and non-verbal responses, in order to ascertain the information needed to deliver appropriate care has been emphasised (NMC, 2010; Ruben, 2016). It has been argued that patient concerns and overall wellbeing are not addressed sufficiently and that communication is a core characteristic of any relationship between health professionals, patients and families (Walsh and Swain, 2011).

Through interpreting Mr Rogers’ reactions, I felt that non-verbal methods of communication such as the use of posture, eye contact, and touch were key methods to engage him in conversation (Mandal, 2014). The influence of the two communication methods (verbal and non-verbal) run parallel with one another (Mandal, 2014), and can be linked to the concept of how we present choices to an individual, known as choice architecture (Thaler and Sunstein, 2008; Johnson et al,

2012). Choice architecture can be used to explain the action of a health professional when describing treatment options to a patient. The health professional may have a subliminal, often overlooked, influence on the decision made by the patient, through ‘nudges’ (Johnson et al, 2012). This happens in a number of ways, such as the order in which choices are presented, the attributes given to each option, and their perceived ease of implementation (Johnson et al, 2012). Thus the way in which information is presented can influence the decision made by the patient (Thaler and Sunstein, 2008). As discussed earlier, Mr Rogers’ suspected ACS led to limited options being offered, meaning importance was placed on the only feasible option (Thaler and Sunstein, 2008).

To initially treat Mr Rogers’ chest pain, I suggested the use of glyceryl trinitrate (GTN) to my mentor for pain relief, followed by further investigations (NICE, 2010). This treatment pathway is known as a ‘default’, an option that is offered and used in the same scenario every time, supported by guidelines and policies unless another is actively sought by the patient (Thaler and Sunstein, 2008). Consent was gained from Mr Rogers before care implementation; however, this treatment pathway can still be classified as a nudge because of its influence from past research on best practice. There is some debate over whether the practice of using nudges is ethically sound because they can be perceived as manipulative, lacking autonomy and carrying bias from the health professional (Sunstein, 2015). A health professional’s preferences towards treatment options can also vary, dependent on their previous experience. This could influence the nudges offered and even the default treatment used (Johnson et al, 2012).

Management Following the explanation to Mr Rogers of his suspected ACS, I administered 1 mg sublingual GTN spray to alleviate pain, in accordance with NICE (2010) guidance under supervision from my mentor. I also administered the prescribed loading dose of aspirin; 300 mg. Using aspirin as part of dual antiplatelet therapy is fundamental first-line treatment for ACS (Bobadilla, 2016). Following this, I carried out an ECG and a physical examination to assess the extent of the pain and its manifestation. Furthermore, my mentor ascertained an initial troponin level, as advised by NICE (2010). As part of the assessment, pulse oximetry was essential to ensure that Mr Rogers did not become hypoxic. Complimentary oxygen therapy can be given and titrated as necessary to maintain oxygen saturations between 94 and 98% (NICE, 2010; Ripley et al, 2012).

Reflection Arguably, the most problematic part of the decision-making process is the health professional as, although personal knowledge and prior experience is invaluable in health care, its successful application to present situations can prove difficult (Carper, 1978). There is the danger of ‘irrational escalation’; the ability to continue to support a hypothesis one has formulated despite new evidence suggesting the hypothesis is futile (Dietrich, 2010). Personal judgement can be seen as subjective and concrete, implying that it is influential in all healthcare scenarios (Carper,

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1978). Bias can be seen as human error, in which retrospective thoughts and beliefs can wrongly influence the present (Vincent, 2010). A health professional might make errors such as absent- mindedness, active failure and a lack of attention to detail in critical moments, leading to potential drug errors and potentially misdiagnosis (Vincent, 2010). Serious cases such as these can be seen as negligence, as the health professional has failed to provide an adequate level of care to the patient (Sohn, 2013; Bach and Grant, 2015).

Contextualising the above, reflective practice is fundamental to self-empowerment, to reflect on one’s self, analyse the experience and learn from it (Enuka and Evawoma-Enuka, 2015; Johns, 2005). Enuka and Evawoma-Enuka (2015) saw reflection as an opportunity to acquire a method of communicating something we had previously not had the experience to do. Reflective practice can be seen as a process of evaluating the events that took place, analysing the impact of these and noting what effect that could have in similar scenarios in the future (Dolphin, 2013). For example, ‘latent failure’; the manifestation of errors through working factors such as person’s lack of knowledge, was a possibility as I was not confident initially in the protocol of treating and caring for Mr Rogers with a suspected ACS (Lawton et al, 2012).

Conclusion Retrospectively applying decision-making models to a scenario experienced during placement is a beneficial way to analyse the processes that are applied when formulating a hypothesis relating to a patient. The hypothetico-deductive model allowed for the use of a systematic approach to formulate hypotheses that were then acted upon to improve Mr Rogers’ outcomes. It was appropriate to discuss normative theories in relation to this model, as the care given to Mr Rogers can be followed using widely recognised management guidelines. However, prescriptive theory is essential in acknowledging the reality of the scenario, and establishing the best possible outcome after consideration of all the relevant information. We are influenced by our own thoughts and feelings, which can positively affect outcomes, so long as they are managed and applied when relevant, because they could be detrimental to patient safety. It was important to keep Mr Rogers central to the decision- making process, an integral method used in health care to allow patients to take control of their condition.

It is also important to discuss pertinent litigation, from problems with documentation to consent and ethical issues, as knowledge of these will help to promote a successful, trusting relationship between patient and health professional, while protecting the former from harm. Finally, reflective practice presents an opportunity to learn about ourselves as health professionals and potentially better prepare for future practice. It allows for the evaluation of specific aspects of the scenario and a chance to learn new skills relevant to patient safety. To use such practice is to empower health professionals and patients alike, ensuring that nurses always have patients’ best interests in mind.

This article sought to describe what influences a nurse’s decision to manage patients in a particular manner. Shared

decision making ensures that the patient’s preferences are at the forefront of any management plan and that it is flexible enough to adjust to the patient’s ongoing needs. Although normative theory is applied in many healthcare scenarios, it requires contextualisation through the use of prescriptive theory so that the best possible outcomes can be achieved. Reflecting on practice allows health professionals to empower themselves to expand their knowledge base to support their patients. BJN

Declaration of interest: none

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Bach S, Grant A (2015) Communication and Interpersonal Skills in Nursing. 3rd edn. Sage Publications, London

Bobadilla RV (2016) Acute coronary syndrome: focus on antiplatelet therapy. Crit Care Nurse 36(1): 15-27. http://dx.doi.org/10.4037/ccn2016497

Capita Group (for Department of Health) (2013) Shared Decision Making Programme Embedding Shared Decision Making in Routine Commissioning Systems and Processes. http://tinyurl.com/zul65rc (accessed 17 January 2017)

Carper BA (1978) Fundamental patterns of knowing in nursing. AdvanceNet Health Solutions 1(1): 13-24. http://tinyurl.com/z9f7u6z (accessed 11 January 2017)

Coulter A, Collins A (2011) Making Shared Decision Making a Reality: No Decision About Me, Without Me. King’s Fund, London. http://tinyurl.com/ ln8tunc (accessed 11 January 2017)

Dietrich C (2010) Decision making: factors that influence decision making, heuristics used, and decision outcomes. Student Pulse 2(2): 1-3. http:// tinyurl.com/z5fz69w (accessed 11 January 2017)

Dolphin S (2013) How nursing students can be empowered by reflective practice. Mental Health Practice 16(9): 20-23. http://tinyurl.com/hompj4o (accessed 11 January 2017)

Elstein SA, Schwartz A (2002) Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ 324(7339): 729-32

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KEY POINTS ■ This article presents a number of theories that health professionals can

apply in practice that help to implement safe and effective care to patients

■ Health professionals can be influenced in the way they present treatment options to patients as a result of personal experiences, and these influences are often subconscious and subtle

■ The treatment options available may be restricted based on what patients present with, supported by robust and up-to-date clinical guidelines provided by relevant organisations

■ Reflection is an important aspect of decision making as it provides an opportunity to consider what has been successful, and what could be learned for the future from the experience

■ Patients should be at the center of any decisions that are made, and ultimately make an informed choice regarding their care

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Ripley D, Riley S, Shome JS et al (2012) Oxygen use for chest pain in coronary care units across the UK. QJM 105(9): 855-60. http://dx.doi. org/ 10.2147/IJGM.S24256

Royal College of Physicians (2012) National Early Warning Score (NEWS) Standardising the Assessment of Acute-Illness Severity in the NHS. Royal College of Physicians, London

Ruben BD (2016) Communication theory and health communication practice: the more things change, the more they stay the same. Health Commun 31(1): 1-11. http://dx.doi.org/10.1080/10410236.2014.923086

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Vincent C (2010) Patient Safety. 2nd edn. Wiley-Blackwell, Chichester Walsh J, Swain D (2011) Supporting Shared Decision-Making: A Pathfinder

Project for NHS North West. Picker Institute Europe, Oxford. http:// tinyurl.com/hoow53u (accessed 11 January 2017)

CPD reflective questions

■ Consider the tool and theories mentioned. Reflect on a scenario where you may well have used any of these

■ Health professionals can have an impact on the decisions that patients make, can you think of some ways that could influence a decision?

■ When implementing a specific care pathway for a patient, can you consider what research, and from what organisations, could have influenced the clinical trust guidelines you refer to?

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