Decision Making in Learning Disability Nursing

This chapter focuses on exploring decision making in the learning disability nursing field of practice. Previous chapters have covered the background about decision making, the principles, tools, and the use of evidence, as well as the way in which decision making fits in with the Nursing and Midwifery Council (NMC) Standards for Pre-Registration Nursing Education (NMC 2010) and competencies. The content of these early chapters and learning will help you to build your understanding of the issues when applied particularly to learning disability nursing skills in practice. This chapter also follows those addressing decision making in mental health nursing, children and young people’s nursing, and adult nursing. This ‘separating out’ of the fields of practice is helpful to give particular clarity and focus to issues relevant within them. It is, however, equally important to remind you that these apparently clear-cut distinctions between the disciplines are not necessarily reflected in practice, and that clients and patients do not always fit neatly into these artificial ‘boxes’. People with a learning disability have a right to equal treatment from registered nurses in adult and mental health settings, and children and young people with learning disabilities should expect the same standard of care as their typically developing peers. The NMC’s The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives (NMC 2008: 3) reminds us that ‘You must not discriminate in any way against those in your care’ and that ‘You must treat people as individuals and respect their dignity’. So, whatever your chosen future field of practice, please read on, because when people with learning disabilities require nursing, they are—and always will be—your responsibility too. Case study 12.1 has been chosen intentionally to highlight the partnership working and decision making that can go on between adult nurse specialists and learning disability nurses. The underpinning value base of decision making in learning disability nursing today is best understood with brief reference to the past. It is in recent memory for many service users that ‘home’ was a long-stay hospital ward or villa, which, despite the best efforts of nursing staff, would invariably be managed along quite regimented lines.

Learning from Decision Making

This chapter explores the concept of learning from your experience in clinical practice, and is designed to help you to use reflection as a means of learning both to make decisions in practice and to learn from the decisions that you have made. The use and value of reflective practice will be explored in many of the chapters to come; it is considered to be essential in the development of decision-making skills as a student nurse, and for your ongoing personal and professional development as a qualified registered nurse. Learning from experience is often referred to as ‘experiential learning’ and one of its key skills is reflection. In other words, reflection is the key to helping you to use experiences as a student and a person in order to learn from them. This chapter will provide some definitions of reflection and will introduce some commonly used frameworks or models that can help you to develop the underpinning skills required if you are to be a reflective practitioner. There are also activities for you to complete, so that you can begin to use a range of different frameworks that are appropriate to different situations. To place reflection in the context of your learning to become a nurse and therefore to achieve the appropriate competencies, the Nursing and Midwifery Council (NMC) states that: We can see from this statement that there appear to be some key assumptions and activities that are seen as working together, including reflection, and these will be explored particularly in this chapter. Reflection on practice, and subsequently for learning from this practice, will be two of the most important aspects that will be addressed. To begin with, however, we need to consider some of the underlying principles in which reflection and reflective practice are embedded. Learning from our experiences means that we can either use what we have learned to develop and to enhance future experiences, or alternatively that we can learn from any mistakes that we may have made in the anticipation that we will not make the same ones again.

Making Decisions as A Student: Decision-Making Opportunities

This chapter introduces the underlying principles of decision making. You will be encouraged to consider decision making as a student in university together with decision making as a student nurse (see Chapter 1 ). In 2010, following a review of pre-registration nursing education, the professional body for nursing in the United Kingdom, the Nursing and Midwifery Council (NMC), published new Standards for Pre-Registration Nursing Education , including competencies that all students must achieve to qualify as a registered nurse. These competencies have to be met in four broad areas known as ‘domains’. 1. Professional values 2. Communication and interpersonal skills 3. Nursing practice and decision making 4. Leadership, management, and team working You will find reference to these domains throughout the book, and there will be an opportunity to learn how the competencies in each of these that relate to decision making can be linked to your clinical and university-based learning. There are a number of terms that can be found in the literature that are often used interchangeably; you may see terms such as ‘decision making’, ‘problem solving’, ‘clinical reasoning’ or ‘clinical judgement’, and others used when writers are discussing how and why nurses respond to clinical situations in a particular way (see Chapter 1 for more detail). For example, Levett-Jones et al. (2010: 515) provide a helpful definition of clinical reasoning as ‘the process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process’. They also emphasize that a nurse’s ability to develop these clinical reasoning skills depends on what they term as ‘five rights’—that is, the nurse’s ability ‘to collect the right cues and to take the right action for the right patient at the right time and for the right reason’. In the context of ensuring that any patient receives the best possible care, these ‘five rights’ are very appropriate, and indeed if one were to fail to pick up on the right cues and to take the appropriate actions in many clinical situations, the outcome may have serious repercussions for the nurse and the patient.

Nursing Practice and Decision Making

You have already seen in earlier chapters that decision making is the cognitive process of reaching a decision—of considering a number of options from which only one can be chosen. Student nurses need to develop knowledge not only of generic nursing skills, but those related specifically to their chosen field of practice (NMC 2010). So how much knowledge do you need to be a nurse and how do you know when you have acquired it? It is often said that ‘a little knowledge is a dangerous thing’—a saying attributed to Alexander Pope (1688–1744). In nursing terms, this could mean that this small amount of knowledge can potentially mislead you into thinking that you are more competent than you actually are. How much knowledge is required to ensure competency as a qualified nurse is not easily determined, however, because we all learn in different ways and over time. Lifelong learning is advocated for all nurses and, indeed, is a requirement of continued registration (NMC 2011); as a qualified nurse, you will be making decisions on a daily basis for the rest of your working life, which will require you to be aware of best evidence for practice and patient care. The nature of these decisions forms an important part of this chapter and there will be a number of case studies related to all fields of practice for you to consider. It is important that you do not consider and answer only those related to your own field of practice, because you might encounter a situation in which you might have to care for a child or young person on an adult ward in hospital, or during a home visit in the community: for example, a grandparent might suddenly complain of feeling unwell and collapse whilst visiting his or her grandchild on a children’s ward. The Nursing and Midwifery Council (NMC) reminds us that nurses’ decision making must also be shared with service users, carers, and families—that is, that we must work with people to ensure the best and most appropriate decision for their needs at that time (NMC 2010).

Decision Making for Transition to Registration and Preceptorship

This chapter will explore and discuss issues that may impact on your transition from third-year student nurse to newly qualified nurse (registrant). The issues that will be explored include delegation skills, challenging others, accountability, and prioritizing skills. Case studies will be included that will help you to consider how to respond in some situations that you may encounter. There are no right or wrong answers, but it is important to reflect on the many ways in which decision making occurs in terms of how you might act in certain circumstances. (See Chapters 9, 10, 11, and 12 for illustrations from actual practice situations.) Based on the case studies described in the chapter and on the experience of the authors, top tips will be offered to help you to consider a range of options to deal with the identified problems. It is hoped that the chapter will help you to plan key goals to achieve in your final placement, and to identify specific developmental goals to facilitate your transition to registered nurse and during your preceptorship experience. ‘Transition’ can be described as a challenging process that involves moving through a period of uncertainty from a familiar to an unfamiliar role. It is defined by Kralik et al. (2006: 323) as ‘a passage from one life phase, condition, or status to another’, often linked with a life-changing event. However, Meleis et al. (2000) state that change does not necessarily result in a transition and in fact change, according to Bridges (2003), is situational, whereas transition is psychological. Transition is a natural progression throughout life and, even though it can be actively sought and positive, it may be stressful as a result of psycho-social alterations (Brown and Olshansky 1997). Bridges (2004: 4) describes transition as being ‘composed of three stages: an ending, a neutral zone and a new beginning’. The first step is letting go, or ending, a past or former self; the next step, the neutral zone, is identified as a critical point for psychological readjustment; the final step is a new beginning. Bridges (2003) discusses fear of the unknown within the neutral zone, a stage of being in-between the end of the old and the beginning of the new.

Decision Making in Adult Nursing

This chapter explores clinical decision making in the field of adult nursing practice. It draws upon the actual experiences of a third-year student nurse prior to qualifying as a nurse, to provide real-world examples of the types of decision that you, as a student nurse, will face whilst out on placement and once qualified. The case studies include learning exercises for you to complete, which aim to explore how you might have addressed the situation and made decisions. This will help you to develop skills for safer professional practice and to put the patient at the centre of your decision making. The role of the nurse has grown significantly over recent years as a result of changes in health policy, enabling the nurse to take on far greater levels of responsibility, such as independent nurse prescribing and advanced levels of nursing practice. This has resulted in nurses working in an increasingly complex clinical environment. On a daily basis, nurses are required to make decisions in relation to the care that they provide and how they manage their individual workloads (Banning 2005). As such, clinical judgement is considered to be an essential skill (Tanner 2006). Nurses now have far greater independence over their decisions in clinical practice owing to the influence of the changing policy context (Thompson 2001). However, this level of independence brings increased responsibility to the nurse, who will be judged and held accountable for his or her actions. Nurses are frequently required to make decisions in practice, often with limited information available to them (Ellis 1997). This requires critical thinking and problem-solving abilities, which are important elements of student nurse education (Garrett 2005). Clinical decision making is a highly complicated process, not yet fully understood, and there is considerable debate relating to its constructs and definitions evident in the literature (Shabban 2005). Furthermore, a variety of terms are used interchangeably within the literature referring to clinical decision making, which demonstrates a lack of consensus and may cause confusion: ‘clinical judgement’, ‘clinical decision making’, and ‘clinical reasoning’ are phrases used interchangeably to discuss and describe similar activity (Maharmeh 2011).

Mental Health Nursing and Decision Making

The chapter first explores the issues involved in how and why mental health nurses come to learn about the decisions that they need to take in clinical practice, and why these are crucial to the establishment and maintenance of therapeutic relationships. It must be noted that various terms will be used throughout this chapter that refer to individuals requiring care and support from nurses—that is, ‘patients’, ‘service users’, and ‘clients’. We will also explore some of the challenges and tensions that can arise when there is a difference between what the professional and the service user might feel is the right decision. Reference is made to the prevailing mental health legislation in the United Kingdom and, in particular, the legislation around care being provided possibly against an individual’s wishes and while he or she is living in the community. If you are not living or studying in the UK, you should seek out the relevant legislation that applies to your country. You might want to see where the similarities and differences are between that and the UK legislation. The chapter concludes with a discussion of how the mental health nurse can ensure that inclusive and informed decision making leads to safe, secure, and effective mental health care. By means of the case studies and the discussion, it will enable you, as the student nurse, to learn how different kinds of decision making can influence outcomes of care, and it will also help you to work towards achieving the Nursing and Midwifery Council (NMC) competencies as they relate to decision making in nursing practice. Note that while the case studies are based on real-life examples of decision-making situations, all names in the case studies have been changed, in keeping with The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives (NMC 2008). Mental health nurse education, practice, and research have long championed innovative approaches to improving our understanding of the impact, on individuals, the communities in which they live, and wider society, of the decisions and actions taken in the name of therapeutic endeavour.

Decision Making in Children’s and Young People’s Nursing Practice

The purpose of this chapter is to address decision making in the field of children’s and young people’s nursing practice in relation to the field-specific competencies outlined by the Nursing and Midwifery Council (NMC) in the Standards for Pre-Registration Nursing Education (NMC 2010). In order to explore these competencies further, we will consider examples from practice, and links will be made between the various examples from practice and the competencies in order to demonstrate their importance. To allow an in-depth exploration of the examples from practice, we will use Johns’ (1994) model of reflection. ‘Reflection’ is described as a means by which nurses can closely examine their theoretical knowledge along with their nursing practice (Johns 2000). The process of reflection has been found to have great benefits for nurses, because it allows them the opportunity to change and develop practice in order to carry out improved care practices (O’Regan and Fawcett 2006). In this chapter, the evidence of decision making has been interlinked with critical evidence-based reflective practice, and demonstrates its integration and development in the role of the newly qualified nurse. The chapter will begin by discussing examples derived from practice, and key aspects from these examples will be taken and related to the NMC Standards (NMC 2010). The chapter will then go on to discuss key elements required to make decisions in clinical practice. The evidence base for many of the decisions taken in the case study is interwoven throughout the narrative, thus enabling you see how they link together in nursing practice. Centred on a newly qualified staff nurse on the neonatal unit, the single case study around which this chapter is structured considers the care of a sick neonate whose parents were adolescents. This example was chosen because it illustrates many aspects of caring decisions that have to be made for patients from birth through adolescence, because the parents themselves were still in the later stages of childhood. The case study itself appears as dialogue, and the Standards and competencies referred to are those generic and field-specific competencies that a student pursuing a children’s nursing field-of-practice pathway is required to achieve, found under the heading ‘Competencies for entry to the register: Children’s nursing’ in the NMC Standards (NMC 2010).

Using Evidence for Decision Making

By now, you have read lots of information on the principles of decision making and why this is so important for you in your nursing practice. It will be invaluable to you as you progress in your nursing career to know how to make decisions in and about nursing practice, including knowing: ● when to make these decisions; ● when decisive action is required; ● when to call a doctor; ● when to withhold a particular medication; and ● when to recommend an alternative nursing intervention. It is equally imperative that you understand why you are making the decisions that you are making and where you might go to find the information that you need to underpin these decisions. The Nursing and Midwifery Council (NMC), in its Standards for Pre-Registration Nurse Education (2010), specifies clearly the competencies that are required upon completion of a nursing programme for entry to the NMC professional register. In its competency framework, four key areas (‘domains’) are identified, one of which is ‘Nursing practice and decision making’, demonstrating unequivocally the emphasis and importance that the NMC places on the role of the qualified nurse in decision making. This domain statement is presented in Box 3.1. Specific requirements relating to this domain can be found in Parts 2 and 3 of this book. In addition, the NMC stipulates, in relation to specific knowledge and skills, that ‘all nurses must apply knowledge and skills based on the best available evidence indicative of safe nursing practice’ (NMC 2010). It also offers guidance to programme providers on the ‘Essential Skills Clusters’ (NMC 2010)—that is, additional sets of skills (‘clusters’ of skills set around specific areas of nursing practice) required to be attained by student nurses at specific points during their programme. The Essential Skills Cluster that is relevant to the use of evidence to underpin practice decisions is the ‘Organisational aspects of care’. Within this cluster, there are a number of descriptors listed that are related to this area, as listed in Table 3.1.

Leadership, Management, Team Working, and Decision Making

It is important that we differentiate between leadership and management right at the outset, and this differentiation can be seen in this statement. However, initially, we will consider both individually and as different facets of what you as a student nurse are required to learn to achieve your competencies to practise as a registered nurse. The concept of team working is explicit throughout this chapter. Recent years have seen the issue of nursing leadership become an important issue for the future of nursing generally, and, most importantly, specifically in relation to the major changes in health and social care, and subsequently in direct nursing care. Patients now require more intensive interventions; bedside technology continues to thrive and, with a more rapid discharge system and quicker throughput of patients in hospitals, many organizations are in search of a workforce who can manage their workload effectively, whilst providing leadership to others. Employers are looking for qualified nurses who can provide supervision, management, development, administration, and coordination of services to patients and employees (Mahoney 2001: 269). In his letter to the Prime Minister summarizing the interim report of the National Health Service (NHS) Next Stage Review (Department of Health 2007: 3), Lord Darzi set out his aim to convince and inspire everyone working in the NHS to embrace and lead change. Every time you go on duty with an aim to care for patients, whatever their number, you require some degree of skill and potential to lead others to help you to collaborate with your colleagues. The Nursing and Midwifery Council (NMC) Standards for Pre-Registration Nursing Education (NMC 2010) now make it explicit how student nurses are expected to achieve competencies in these areas and state in the Standards: Each field of practice also has its own field-specific competencies related to this domain—that is, competencies that are specific to the main service users that are the focus of the respective field of care.