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Right of a Nurse to Be a Part in Decision Making

By: Rozeena Gillani & Safin Tharani.

Nurse: I knew what the doctors were acting was not right according to the situation, and I wanted them to stop, because I knew about the patient more than them as I was serving patient for 24 hours rather than just visiting for 5 minutes. But I was too scared to tell anyone. The doctors who were not performing accurately were mostly employees, who had been working at the hospital for many years and who had lots of authority. I feared what they would do with me if I argue with them … I let the wrong act happen and … I never did resolve the conflict…

In past few years, the rate of incidences related to medical errors by doctors has been increasing day by day. Institute of medicine reported in year 2000 that 44000 to 98000 deaths occur annually from medical errors in the USA. One of the most contributing factor was nurses were only confined for providing hygiene care and follow doctor’s orders. However, the physicians had authority to make decisions regarding patient’s treatment. Till the date, the rights of drug prescription, making differential diagnosis and its management is only possessed by doctors. The issue of decision making autonomy for nurses has remained debatable and long standing tension for many years. Evidence of several conferences held in different countries concludes that nurses are arguing and wishing to increase their autonomy. My contention is that nurses should be given autonomy in decision making for patient’s treatment because they spend more time with patient, enriched knowledge and experiences regarding patient, and unavailability of physicians and doctor at times.

Nurses play vital role for decision making in health care setting and it is not limited to patient’s care and treatment in-fact it is important in taking decisions related to end-of-life issues as well. Situations including withdrawal of life supporting and life sustaining treatment raise anxiety and ethical issues in health care setting especially care for dying patient. In these times, nurses can help more than physician because nurses spend more time with patient than any physician or health care member. According to Senft, Lessner & Sollins (2004), “Nurses also recognize when a change in condition has occurred that can identify when an important decision concerning the patient’s care needs to be made.” Numerous scholars named them as clinical intuitions which defined by Westcott (1968) as, “intuition is a process of arriving at accurate conclusions based on receiving relatively small amounts of knowledge and/or information” (Billay, Myrick, Luhanga & Younge, 2007). However, it is difficult for nurses to verbalize their intuitions in subjective forms but it gives creativity to patient’s care. On the other hand, clinical intuition does not follow scientific reasoning that’s why some offenders claim it as unauthentic. In the ages of modernization, people are more focused and fascinated by evidence-based practice. Intuitions are more related to fluke and gut feelings which do not involve any facts and figures of patient’s assessment whereas assessment is very necessary for any treatment. Furthermore, the argument put forward that nurses become emotional when they come in touch with patient for long times. Under the circumstances of end-of-life issues, emotional attachments of nurses with patient can interfere in clinical decision making. “Some degree of detachments from the situation has its positive aspects … distancing themselves from the death helps nurses to continue functioning” (Thompson, Melia, & Boyd. 2000). Thus, it has been recognized that intuitions should be made in response to knowledge which can be triggered by reflection and experience of nurses and can help nurses to make decisions for patient’s treatment.

Clinical competency is foremost characteristic that is very essential to make decisions related to patient treatment. Clinical competency is defined as having high level of education, skills and experience with the ability to use them timely and properly. As one nurse clarified this definition by saying “a competent and powerful nurse is the one who has rich knowledge and skill and is expert in his/her own job” (Ahmadi, Hagbaghery & Salsali, 2004). The presence of hands on skill with clinical competency help nurses to take wise decisions for betterment of patients. In many scenarios, nurses have proved themselves as more practical in skills and competent than physician. However, nursing errors are greater than medical errors but unfortunately, these reports are not valid because many of the nurses’ do not initiate to report physician’s error. One survey conducted by Cohen & Hedy (2003) reported, “Although many nurses feel uncomfortable reporting a colleague's error, it's legally and ethically right thing to do for the patient's safety. Among survey respondents nurses, however, almost 19% say they never report a physician's error, and 14% never report a pharmacist’s error; only 9% never report another nurse's error” Comments made by opponent indicate their willingness for nurses to assume decision related to physical care of patient but they disagree to involve nurses in making diagnosis and management of disease. They emphasized on critical role of nursing education in decision making and they assume that nurses have lack of knowledge about path physiology, anatomy and other life subjects. Therefore, nursing education, experiences, and competency are significant characteristics for nurses to make any decision. We disagree with the opponents’ idea because in recent curriculum, the subject of path physiology, anatomy, pharmacology and research are being taught to a nurse which makes them all rounder.

Nurses have proved their competency at times when the physicians are unavailable. There have been incidences when due to unavailability of physicians in critical situations, the nurses have acted remarkably. In the study of Ahmadi, Hagbaghery & Salsali (2004) participants shared their successful experiences of insertion of endo-tracheal tube in critical area where doctors were not available and patient was in crush. Under emergency situation, where doctors can not reach on floor, role of nurses considerably change and they have to take some clinical decision on the level of their knowledge. On the other hand, although the nurse’s theoretical knowledge is increasing with new advancement in the curriculum but the knowledge and skills possessed by the doctors is surely greater and cannot be replaced by the nurses. During critical situation, patients condition change rapidly and create climate of high stress. These stressful environment demands high decision making from nurses that’s why nurses have more chances to malfunctioning without physicians. Therefore, nurses should give input in decision making in the presence of physicians to minimize errors and stress.

Hence we would like to conclude that nurses should be allowed to participate in decision making activity regarding patient’s treatment. The association between decision-making and knowledge play a fundamental role in the dimension of patient care. Now a days nurses are Maintaining the focus on their knowledge and skills competency through which they are more able to perform clinical decision making task. Moreover nurses are also involved in research and evidence based practices which had enhanced their knowledge related to the particular disease and patient. Therefore, some gray areas where distinction between medical and nursing domain are found, and doctors are trying to suppress nurses and public is also supporting them because of lack of awareness about the progress in nursing profession.

We would like to recommend for nurses that they should maintain their standards in the field of research and evidence based practice and be pious for their right because they have knowledge, skills and more information regarding patient as they spend more time in clinical area. Moreover, we would like to recommend for the higher authorities that they should involve nurses in decision making conference regarding the patient and definitely you will find the positive change. Additionally, we would like to recommend for doctors that they should support nurses for their hard work so, together we can make the difference in patient care.