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Using the Monologue of Doris Smith to Understand Situational Decision-Making

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Older adults are among the nurse's most complex clients. They represent a broad spectrum of strengths, needs, and expectations. Yet, nurses find themselves wondering if the care decisions they make produce the best outcomes for this population. This teaching strategy will use a monologue of a nurse who provided care for older adult, Doris, to address the need for effective situational decision making. This teaching strategy can be utilized in a variety of teaching/learning situations: didactic lectures; clinical settings such as post- clinical conference/debriefings; simulation scenario debriefings; or small seminar discussions. In addition, the teaching strategy can be used with practicing nurses as a professional development activity, as well as when orienting new graduate nurses.

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Using the Monologue of Doris Smith to Understand Situational Decision-Making

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- Doris Smith monologue
Learning Objectives
Students will:
- Assess the older adult’s individualized pattern and functional status using standardized assessment tools.
- Describe the complexities involved in making care decisions for older adults.
- Discuss the importance of situational decision making based on an assessment of the client when caring for older adults.
- Discuss the importance and strategies for weighing risks versus benefits when caring for older adults.
- Develop an understanding of integrating the RN’s concerns with ethics, policy, and judgment while respecting the older adult’s strengths, wishes and expectations.
Getting Started
This teaching strategy focuses on assessing expectations, coordinating and managing care, and making situational decisions with older adults. The strategy enhances the student’s human flourishing and nursing judgment.

1. Provide the learners with the ACE.S framework and discuss communication techniques when assessing function and expectations in older adults.

2. Using the ACE.S framework, ask the learners to discuss a situation where they were unsure how to balance the expectations of the patient with the institution’s protocol and safety guidelines when caring for the older adult.

3. Listen to or read Doris Smith's monologue. This activity can take place in lecture, seminar, or in pre or post conference for clinical.

4. Review the ANA’s Code of Ethics for Nurses with Interpretive Statements with the students.

The Code of Ethics for Nurses was developed as a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession. Discuss the ethical responsibilities of nurses when providing care to older adults.

5. Discussion Questions: Use the following to facilitate a discussion with your students:
- What are your concerns for Doris? What are your concerns for the nurse giving report?
- What is the cause of the concern?
- What else do you need to know about Doris?
- What are you going to do about it?
- What do you think Doris is experiencing?
- Discuss the issues related to the IV line for Doris.
- Consider the possible outcome if the nurse does nothing in this situation.
- Consider the possible outcomes if the nurse takes action. What are the risks and benefits to Doris? To the nurse?
- What steps should be taken to resolve this ethical dilemma?
- Discuss how nurses can determine if a patient is cognitively intact in making care decisions.
Materials

This video can be used as an additional resource for faculty in teaching ethical decision making in the care of older adults.

"Why is it so hard to die well in American hospitals and what can be done to change that?" Department of Medicine Division of Medical Humanities, NYU Langone Medical Center. By Arthur Caplan, PhD

Dr. Caplan summarized the history of medical decision making over the past fifty years and its implications on contemporary practices. He noted the challenges of communication with patients and amongst the medical community, the influence of the media on medical decision-making and the acceptable definitions of what constitutes informed consent. He suggested pathways for improvement including a more active role for the physician in setting expectations early, communicating clearly and effectively with the patient and surrogates as early as possible and being unified in decision-making across systems in the health-care community.
Suggested Reading

Geist, M.J., & Kahveci, K. (2012) Engaging Students in Clinical Reasoning When Caring for Older Adults. Nursing Education Perspectives. 33(3), 190-192.

Milton-Wildey, K., & O’Brien, L. (2010) Care of Acutely Ill Older Patients in Hospital: Clinical Decision-Making. Journal of Clinical Nursing. 19(9/10) 1252-1260.
Assessment Tools
ConsultGeri.org, the website of the Hartford Institute for Geriatric Nursing at New York University's College of Nursing, contains many evidence-based assessment tools. Located on the ConsultGeri website is a variety of assessment tools on topics relevant to the care of older adults. The How to Try This series is comprised of articles and videos demonstrating the use of the Try This:® series. How to Try This articles and videos are listed under their respective Try This article. Those listed below can be used to assess, evaluate, and discuss the needs of Doris with students.

Visit ConsultGeri.org to access the Try This® and How to Try This resources.
Author Information

Tamika Curry, MSN, RN
Community College of Philadelphia
Philadelphia, PA