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The decision-making in nursing or clinical judgement by nurse for the patient is made by considering the health status and history of the patients and making needs assessment. The clinical decision-making in nursing is important as the judgement creates effect on the healthcare of the patient and the professional action to be performed for supporting their health (Nibbelink and Brewer, 2018). In this study, the Caper's fundamental ways of knowing are to be used to critically analyse and discuss the clinical decision been taken by the nurses for Nat. Moreover, Caulfield's pillar of accountability is to be used to critically analyse the professional context considered in making the decision of care for Nat.


Decision-making process

In nursing, the decision-making process includes developing conclusion regarding the health of the patient and needs with the determination to implement best care actions for meeting the needs of the patients so that they are satisfied with the care and show improved health outcome (Truglio-Londrigan & Slyer, 2018). The nurses in making clinical decisions are seen to consider various sources and access opinion as well as preferences of the colleagues along with determine the policies as well as procedures to develop high standard of care. This is because it leads the nurses to develop different hypothetical decision and determine from them the best suitable care to be delivered to the patient (Standing, 2020). The decision-making tools in nursing commonly used include Caper's fundamental ways of knowing and Caulfield's pillar of accountability. The Caper's fundamental ways of knowing mentions four key patterns of knowing which influences the nurses in making clinical judgement of care for the patients. The four patterns are empirical knowing, personal knowing, ethical knowing and aesthetic knowing (Swift & Twycross, 2020).

Empirical Knowing

The empirical knowing is referred to the factual knowledge retrieved from scientific analysis, clinical evidence, existing patient reports and other external sources which are verified by effective observation and the results are documented in patterns of behaviour through the experimentation (Swift & Twycross, 2020; Carper, 1999). In nursing process, the nurses collect empirical information from variety of evidential sources which ranges from patient health assessment and observation, research studies, existing patient record with similar health complications and others to develop empirical knowledge in deciding the patient care (Schwind & Manankil-Rankin, 2020). Thus, the nurse caring for Nat is considered to encompass empirical knowledge regarding evidence-based care from dementia care guidelines, common complications in dementia patients, urine release amount in normal condition and others to successfully care for Nat. This knowledge may have been used by the nurse caring for Nat on listening regarding her low urine amount and nature of colour of urine to deduce that she is suffering from dehydration and required increased fluid input in the form of water. It is evident as empirical evidence from the study of Nagae et al. (2020) informs that dementia patients often suffer from dehydration as they forget to drink enough amount of water due to their hindered psychological state. This causes low urine output in them along with make them suffer dried skin showing lack of fluid in the body.

The study by Fukushima et al. (2019) informs that people with dementia often suffer from dry mouth and lips due to their lack of drinking of enough water. This is because the signal in their body does not act effectively to indicate the patient regarding thirst in strong manner. This empirical knowledge may already be available for the nurse caring for Nat to determine that she needs increased fluid input due to which she asked Nat to drink more water. According to the NMC Code of Practice, the nurses are allowed to ask and share opinion and perception of care with the colleagues to develop best care decision for the patients (NMC, 2018). Therefore, the nurse caring for Nat may have also sought advice from her colleagues to decide of creating a fluid chart where her fluid intake is to be monitored and reviewed to support her overcome dehydration.

Ethical Knowing

The Caper’s ethical knowing is regarding attitude and knowledge developed from the ethical framework by the nurses which involves awareness of moral choices and question (Swift & Twycross, 2020; Carper, 1999). Thus, it is mainly regarding the nurses to know what is their right duty to be executed and their ethical obligations in care. The four key ethical knowing for nurses are professional autonomy, beneficence, nonmaleficence and justice (Beauchamp & Childress, 2013). The professional autonomy means making the nurses have authority to develop decisions and freedom to act as per their professional knowledge base to deliver care to the patient (Rouhi-Balasi et al., 2020). In case of the registered nurse of Nat, she represented effective ethical knowing of professional autonomy as she freely took the decision of ensuring increased fluid intake by Nat on first report by the nursing assistant that Nat is producing small amount of urine which is also yellow in colour. This indicates that she is competent and have the courage to take care of situations based on professional knowledge. The justice in care means the nurses know they are to distribute care fairly and equitably without ignoring anyone (Black, 2019). The registered nurse caring for Nat have enhanced knowledge regarding fairness as she avoided to attend Nat by ignoring others during the medicine rounds and asked the nursing assistant to immediately provide the care to Nat. Moreover, as the registered nurse got the rounds to be cared for Nat, she immediately took the care action and determined the further support required by her to have enhanced health condition.

The beneficence from the professional context means that the nurses are to know regarding the way to provide mercy, kind and charitable care with strong connotation to execute good to others (McCullough, 2020). In case of registered nurse and nursing assistant of Nat, it is seen that both showed effective knowing of beneficence as ethical principle in care as they developed care which could help to increase the urine amount of Nat to normal level and avoid her lip to feel dried in turn creating beneficial health care for Nat. The knowing regarding nonmaleficence among the nurses means they have the knowledge regarding the way to avoid risk for the patient and protect them from any harm (Rubio-Navarro et al., 2019). In the care of Nat, the nursing assistant and the registered nurse have effectively knowledge regarding nonmaleficence due to which they took immediate action to provide care for Nat to resolve her issue with urine amount without waiting the medication rounds to end. This is because they know delay in care would lead Nat to become further dehydrated which is harmful to his health.

Personal Knowing

The personal knowing means the nurse has knowledge as well as attitude developed from personal empathy and self-understanding to be aware of self and others in any relationship. This also means the nurses have values and views regarding the influence of their responses and way they could interfere with objectivity in decision-making process (Thorne, 2020). In care regarding Nat, it was seen that the registered nurse took decision of care by personally being aware of the situation in which Nat current is present. It is evident as she understood that being a dementia patient, she could have also avoided to take water that may have made her dehydrated like Nat. Therefore, fluid chart is required to improve her health condition along with monitoring as she personally perceive that being a dementia patient it is not easy memorise instruction to take water as in such condition the patients have loss or deteriorated memory functioning.

Aesthetic Knowing

The aesthetic knowing is being aware of the nature of clinical situation and developing understanding regarding what it means for the patient (Bender & Elias, 2017). The presence of dementia is regarded to be miserable as the person with progressing age initiates to lose memory followed by develop hindered mobility which interferes with their activities of everyday life (Gundo et al., 2020). Caper (1978) informs that being empathetic and compassionate are the core skills for aesthetic knowing among the nurses. This is because it leads the nurses to remain near the patients and understand their thoughts through self-reflection (Carper, 1999). In case of Nat, the registered nurse and nursing assistant both expressed compassion and empathetic behaviour towards the patients by not being forceful towards care and ensure support is provided to enhance her health condition. This ay they represented that they have effective core skills of aesthetic knowing to be implemented in care.

Nursing Accountability

In decision-making for care, the nurses also require showing accountability and otherwise they would be unable to improve the value of patient care and reach enhanced care judgement. According to Caufield (2005), the four pillars of accountability in care are ethical, professional, employment and legal. In making ethical care decision regarding Nat, the nurse as well as the nursing assistant needs to consider their accountability. In regard to employment accountability, it is the duty of the nurse to be accountable toward her employer set by the contract of employment. The professional accountability of the registered nurse means that are professionally answerable for their actions or any form of mission in the care irrespective of whether they are executing the actions due to their own initiative or following anyone else’s instructions. This is because professional accountability in not only following rules but also being able to understand the alternatives and consequences of the care in the light of best available evidence (Krautscheid, 2014). Thus, the registered nurse for Nat is professionally accountable to provide enough reason for setting the fluid chart and monitoring care action for the patient as well as have perception that the consequences of care decision would be beneficial for the patient.

In relation to legal accountability, the nurse requires to know and be aware of the legislation and policies that direct their care action and practices for the patient. According to regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014, the nurses are to recognise the rights of the patient and provide them enhanced and sufficient information regarding care so that they can freely provide informed consent regarding their care. The informed consent is a must action to be followed by the nurses in delivering care to any patient (, 2014). The Mental Capacity Act 2005 inform that the decision of care may be taken on behalf of the patient when they lack mental capacity to process information and develop relevant decision for the best care (, 2005). In case of Nat, it is already mentioned that she is suffering from dementia and is unable to articulate her needs. Thus, the nurse caring for Nat effectively played their ethical accountability according the Act to take decision on behalf of the patient to put her on fluid monitoring. This is because she is unable to take enough fluid due to her dementia state and cannot mention decision regarding what other care to be provided to resolve her progressing dehydration as seen from skin analysis and urine condition.

According to nurse’s employment contract, a registered nurse is to carry their key duty of delivering seamless and quality care and support to any patients for their enhanced health condition which is also set out by the nursing regulatory body that is Nursing and Midwifery Council in the “Prioritise Care” (NMC, 2018). Therefore, the registered nurses acting to involve in caring for Nat during her rounds and while providing her medication expressed her employment accountability by delivering and suggesting appropriate as needed according to her health condition. The common employment accountability of the nursing assistant is to deliver basic care by consultation with the registered nurse and support the patients in activities of daily living which they are unable to perform due to their hindered health condition (Duffield et al., 2019). Thus, the nursing assistant under the employment accountability acted to inform the basic health condition that is urine output of Nat to the registered nurse to determine the care action to be taken that is supporting her drink more water. According to Roper-Logan-Tierney model, on the activities of living is drinking and eating (Holland & Jenkins, 2019). Thus, the nursing assistant by supporting drinking activity of Nat which she is uncappable to perform due to current confused state caused by dementia also performed her employment accountability.

The ethical accountability is readiness of the nurse to take responsible and moral actions by considering the ethical principles of nursing. According to Beauchamp & Childress (2013), the four key ethical principles of nursing which the nurses are accountable to follow are beneficence, autonomy, justice and non-maleficence. The autonomy means the nurses are to uphold the freedom of choice of the patients and their dignity in making decision regarding their care with effective informed consent (Beattie et al., 2019). However, tension may be raised while supporting the patient’s autonomy as ethical accountability by the nurses. This is because the resulting decision may not be optimal or correct for the health of the patient from the clinical viewpoint to create best outcome for their health (Hoek et al., 2019). In this context, the nurses are allowed to make influence on the decision of the patient by providing them adequate information about the positive and negative consequences of their determined care decision (Hoek et al., 2019). This is because failing to execute it would make the nurses violate the other ethical accountability that is beneficence which indicates that care actions are to be performed that are beneficial for the patient’s health (Pope et al., 2016). Therefore, the registered nurse and nursing assistant attending Nat are required to provide enhanced information to the person who would take care decision on Nat’s behalf to ensure the autonomy is followed without compromising the beneficence for the patient.

The person-centred care approach is one in which the patient is kept in the centre of care for taking all decision so that the care actions are specific in meeting the demands and needs of the patients (Haydon et al., 2018). Thus, the person-centred care is to be used by the registered nurse and nursing associate caring for Nat as it would help them to show effective ethical accountability of beneficence toward her health. This is because it would make them understand the key needs and demands of Nat that are specific to her current health condition and accordingly provide care which is appropriate and beneficial for her health. The non-maleficence indicates avoiding to harm or inflicting least harm possible to any individual for reaching beneficial outcome for them (Jafari et al., 2019). For example, withholding to decide care for Nat regarding fluid chart without her family’s involvement may be violating the rights of the patient or their family in providing informed consent of care. However, executing the care where proper fluid chart is been developed without waiting for the response from the family of Nat would help to ensure her better health. Thus, the non-maleficence was effectively followed as ethical accountability by the registered nurse in caring for the patient. The justice means providing opportunity to each individual or group to have equitable resource and care (Caufield, 2005). In this case, it was seen that registered nurse and nursing associate provide equitable and justified care for Nat by effectively taking immediate action to resolve her dehydrated state.

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The above discussion informs that the registered nurse and nursing assistant caring for Nat has enhance empirical knowing as they based their care decision on available scientific evidence and knowledge. Moreover, they have enhanced personal knowing which they reflected by developing the care for Nat without complaining regarding her health situation where she cannot cooperate with them. They also expressed enhanced ethical and aesthetic knowing by providing morally accepted care and immediate care action to the patient. In regard to accountability, the registered nurse and the nursing assistant expressed high ethical accountability by following all the rules of care along with professional accountability by following professional values at the work as mentioned by the NMC.


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