My Evaluation Of Right Decision Making In Nursing Career

Reflecting upon one’s achievements and errors is a crucial aspect of nursing practice, and provides an opportunity for growth and professional development (Pierson, 1998). Through reflection, health professionals can make sense of challenges they have faced and develop a greater understanding of what occurred, and how to approach future situations differently the next time they arise (Kemp & Baker, 2013). I will be critically analysing a scenario that personally challenged me at the beginning of my nursing career, relating to a stressful situation and the impact that this had on clinical reasoning, judgement and decision making. This assignment will then cover strategies derived from research on how to manage situations such as these, when they occur in the future. I will be using The Gibbs Reflective Cycle (1988) as a framework to explain a situation, discuss it, analyse it, and reflect on it, through the cycle’s six step process. This reflection is focused on the Careful Nursing dimension of Practice Competence and Excellence, in particular, clinical reasoning and decision making.

Description

One day on a busy morning shift in a rehabilitation ward, I was looking after an elderly patient receiving rehabilitation after being diagnosed with an epidural abscess, with a history of delirium. He was receiving antibiotics as the main medical treatment for this, and was often in pain, especially depending on what angle he was at whilst sitting up in his bed or chair. I established that managing his pain effectively was one of the main goals of my nursing care plan for the day. For analgesia, this patient was prescribed regular paracetamol and additional oxycodone if he needed it. On the medication chart, there was a note from the pharmacist, stating to monitor for delirium before and after administering the oxycodone. I had looked after this patient the previous day, and his pain had been well managed with the regular paracetamol. However, on this day that I am reflecting on, he requested some stronger analgesia, despite me keeping up with administering him paracetamol at regular and safe intervals. As he only had oxycodone as an alternative analgesia, I decided to give him this. I was conscious of the pharmacist’s instruction on the chart regarding delirium, but dismissed my thoughts of debate over giving the medication to this patient, and made the decision to give this patient a half dose of oxycodone, after checking for allergies and completing the five rights of medication administration.

Following ward policy, I got a second check on the medication, but I decided that starting with a small dose of the opioid would be safe, and I didn’t need to discuss this with someone higher. The patient had received this medication as a small dose a number of days prior, and nothing had been documented of adverse reaction. The ward was very busy on this day, with a combination of stable and unstable patients. Workloads for each nurse were heavy, and I felt that I had so much ahead of me to do with all of my patients, that I didn’t have time to question something like this. After a period of time, I assessed that the patient’s pain had reduced, however, the patient had become confused compared to what he was the previous day and that morning, and I immediately linked this to the likelihood that this was drug induced and caused by the oxycodone.

Feelings

I felt guilty about the situation, as I had caused a minor delirious episode and could have compromised patient safety, one example being that I had potentially increased his falls risk. I also felt that if I wasn’t so busy on the ward at the time, I may have not dismissed my instincts and rushed my clinical decision to give the patient the medication. I feel that I should not have let everything else on my workload compromise my decisions and thoughts. On the other side of things, I felt that what I had done wasn’t extremely wrong, and there was some rationale behind it. I had not made a drug error, I had titrated the dose due to thinking about his history of previous delirium, I had noted the pharmacist’s instructions, and I had administered the medication safely, getting a second check from another member of nursing staff, and I had carried out the five rights. I also communicated with my clinical nurse manager, my nurse preceptor, and the next nurse at handover, of the event.

Evaluation

This experience was a memorable one, and in being so, it has remained dominant in my mind the negative and positive effects of opioid administration, particularly on elderly patients with comorbidities. I have been more vigilant since this event when administering opioids, which I believe has bettered my practice in this area of nursing, however I felt that it was at someone’s expense. I ensured that the required resources were in place to keep this patient safe until the event was over, such as, notifying my colleagues on the ward, updating his care plan, attaching a patient alarm and increasing my amount of intentional rounding.

Analysis

From reflecting on this situation in retrospect, I can see that there were other factors that contributed to this outcome. One of them being, a busy ward and workload, causing some stress to me, and in return, less critical and clinical thinking and reasoning. I can now see that if I had utilised the nursing council competencies more efficiently, such as direction and delegation, I could have better managed my time, and created a more positive outcome for this patient.

Conclusion

I believe that, after reflecting on this situation with my nurse preceptor and within myself, I could have handled this situation differently. I could have discussed the decision to administer this medication with the medical team. I could have discussed administering this with anyone else I feel comfortable talking to from the medical or nursing team, and I could have also discussed the situation with the pharmacist who wrote the note on the patient’s medication chart.