Nursing Leadership: Decision-Making in Maternity Clinic (NUR567)

This assignment presents a detailed case study from a maternity clinic, focusing on a nurse's critical decision-making process during a complex delivery scenario. The case involves a 19-year-old patient with a history of complications, prolonged labor, and anxiety. The nurse faced challenges including a crowded operating theatre and the patient's physical condition. The nurse had to make a difficult decision to proceed with a vaginal delivery after consulting with colleagues, which led to postpartum hemorrhage due to a cervical tear. The assignment analyzes the application of critical thinking, creativity, and problem-solving skills, highlighting the importance of patient assessment, diagnosis, planning, and implementation. The nurse's actions and the outcomes are evaluated within the context of nursing leadership and management principles. The assignment also discusses different patient care delivery systems, specifically the total patient care (case method) used in the maternity hospital, and it's advantages and disadvantages.

Student’s name;
Course unit;
Institutional affiliation;
Honorary lecturer;
Date of submission;

Question 1
In every hospital informed decision making is important, it is a very crucial and essential aspect
of care that is delivered to the patient, nurses are required to make decisions of care to patients
continually (Chodzaza et al.,2018). Decision making involves critical thinking, creativity and
problem-solving skills, it also needs a reliable source of knowledge, and a reliable source of
information as this influences the effectiveness of clinical practice. Am working at a maternity
clinic, providing nursing care services specifically delivering. One patient that got my attention
after a thorough observation was a 19-year-old female who is at 39weeks gestation. She has no
allergies or history of chronic illness, and this is her second pregnancy with a history of the
previous scar. She was not able to give birth through spontaneous vaginal delivery because she
had prolonged labor which was more than 20hours which and she gave birth to a baby with
cerebral palsy. She had extreme anxiety which was as a result of fear of the whole process of
giving birth (Hildingsson et al.,2017). After assessment and history taking, I noticed that she had
stress which made her very vulnerable which came due to her upcoming operation, pain and fear
of losing her baby. I took my time and decided to speak with her. She explained to me how she is
scared and that she had not received enough rest the night before because she has been
experiencing contractions which were not regular. They lasted for less than 30seconds that night,
but they were not radiating to the back, she got admitted with a diagnosis of the active phase of
labor and pain radiating to the back. Membranes had not ruptured, and I had to do artificial
rupture of membranes, I did head to toe examination and assessed fetal movements, which were
regular. To ease the anxiety, I tried talking to her because my role as a nurse is to make patient to
remain calm and encourage her that all will be well. I monitored her using pantograph where
contraction were regular, fetal heart rate regular, vital signs that is blood pressure, temperature

heart rate and pulse normal had already dilated 4cm. I did close monitoring of my patient as she
waits for scheduled caesarian section surgery, and she was progressing very well. I checked the
fetus and normal contractions every 30mins because the patient was in the active phase of labor
and cervix had dilated 6cm, she was so hypoglycemic and dehydrated, and I gave her five
percent dextrose and a lot of fluids as I waited for her scheduled surgery which was 4hours. That
day was not a lucky day for my patient and me because the theatre was crowded with
emergencies and my patient had to wait a little bit. However, then the contractions were getting
stronger and the pain intensified, and there was no chance of her getting to theatre sooner, and
that is when I had to make a life decision for the patient and the baby on whether to let the child
die or live. I had to take chances and deliver my patient through spontaneous vaginal delivery,
but after consulting with my colleagues and after assessing her ability to giving birth
successfully. I made sure she is hydrated and had had the energy to push to avoid baby getting to
distress due to prolonged labor. Delivering patient with the previous scar, which is less than one
year is dangerous (Timor-tritsch et al.,2016). I administered syntocinnon intravenously for
stronger contractions, it was hard. However, fortunately, she was able to deliver through vaginal
delivery after a long struggle has the patient had no energy to push, a lot of anxiety and fear of
the previous scar to rupture, delivery was successful. However, unfortunately she developed
postpartum hemorrhage which came to a result of a cervical tear. It was a danger sign, and the
patient was bleeding profusely. With the help of fellow nurses, we had to make quick
interventions. To cannulas were fixed and we had fluid running that is normal saline. We
administered uterotonics that are misoprostol and bleeding reduced (wright et al.,2017)as we
scheduled her for theatre for the repair of the cervical tear.
OUTCOME

Patient delivered successfully through spontaneous vaginal delivery a life baby who weighed
3200g and APGAR score of 9 at one minute, 10 at 5 minutes and 10 at 10 minutes. She was able
to get to the theatre, and the tear was repaired successfully and she was wheeled back to the ward
conscious and little bleeding, she was admitted for 5days where she recovered, the baby was
doing well and breastfeeding. She was discharged stable, with instructions and drug
prescriptions that is antibiotics and analgesics which she will take them home, I gave her
education on postnatal care, danger signs that she will notice on the baby which requires
immediate intervention. From that, it is well known that decisions made by nurses and medical
practitioners concerning the health of the patient require critical thinking and decision making,
which ensures quality care is provided to the patient.
b) HOW CHAPTER NINE IS APPLIED IN THE CASE
Critical thinking is making a clear assessment and evaluation of the situation before taking
action(Mcperck,2016). It is an important skill for students who practice midwifery and qualified
as well. Critical thinking through nursing process involves four stages that are assessment,
diagnosis, planning and implementation of various skills. In the case above every stage of critical
thinking is included. Through assessment I was able to identify patient, I did a physical
examination to identify any anomaly, I observed that she was extremely anxious, I took history
to get important data about her pregnancy and previous illness and surgeries. On diagnosis, I was
able to find the problem that the patient was in an active phase of labor and pain. She has a
history of the previous scar, which is less than 1year, which made the patient be qualified for
caesarian section, and this showed that there is a relationship between. Through planning, I used
partograph to monitor labor, I followed up for scheduled surgery, and because of a situation
where theatre had a lot of unplanned emergencies I planned for vaginal delivery which was risky

to the patient, I had to decide on saving both lives of both baby and mother by taking chances
that is when I implemented by applying knowledge acquired in class to conduct successful
delivery. On evaluation, the delivery was successful, but there was a complication of postpartum
hemorrhage due to cervical tear, and she was taken to theatre, and it was repaired successfully.
Through critical thinking, I was able to give essential patient care and saved both lives.
According to Mcchlery(2019), creativity as part of critical thinking is essential, and I was able to
put in action new solutions which were an alternative to the planned solution that failed. It
requires preparation and working together. I was able to pick that one task that was delivering
through vaginal delivery and implemented. Creativity is based on knowledge learned from a
class or from a reliable source.
Problem-solving is done when there is a gap in a situation that is what is going and what should
be going(Kim et al.,2016) on for example in that scenario what is going on is the patient being
delivered through vaginal delivery while and what should be going on is delivery through a
caesarian section which failed because of unplanned emergencies. Before solving the problem, I
had to make sure I was sure and exhausted all the possible solutions. The problem-solving
method I used was trial and error. This is where there is a trial of many solutions to solve a
problem until it is fully solved. In that scenario, one solution was tried, and it worked well for the
patient, for a trial and error to work it needs proper experience, ready and enough resources for
example availability of ready delivery packs and drugs. Trial and error are very time-consuming.
The problem-solving process used in that scenario includes defining the problem, and the
problem was there was no space in theatre and the patient had previous which was risky
delivering through vaginal delivery. Defining the problem requires an accurate assessment of the
problem. Gathering information is another step which involves proper research from a reliable

source, information is analyzed, and the proper solution is identified and implemented, which is
then evaluated.
Decision making is the process of choosing the best alternative solution from the many solutions
to solve a problem. Before making a decision as in the scenario above, there are steps I used as a
nurse which include identifying the need to make the decision, for example, if patient life is in
danger or unavoidable circumstances such unavailable space in theatre which leaves the option
of delivering through spontaneous vaginal delivery. Before making that decision, I was able to
seek the alternative and weigh the risk and benefits. Critical thinking, creativity and problem-
solving skills are required in order to make informed decision making which helps in providing
quality care to the patient(Wechsler et al.,2018).
Question 2
In nursing, patient care delivery system refers to the various in which health services are
delivered (Shi, & Singh, 2014). It varies from one facility to another and may also depend on the
patient circumstances. It involves the way we care for our clients, relatives, colleagues and selves
with our nursing values. The various types of patient care delivery can be classified into two
groups; the traditional methods and in advanced methods. The traditional methods include; total
patient care (case method), team method, primary nursing model, functional model and the
modular delivery model (Fernandez et al. 2012). The in-Advanced methods include; practice
partnership model, case management, critical pathways and differentiated practice. The
significant role of a professional nurse in the first-line management position is the organization
of the staff activities into a functional model in order to meet the needs of a client/patient. Each
care delivery system has its own advantages and disadvantages. None is classified as an ideal
method. Therefore, the method should be selected based on various factors to suit the working

environment and also promote the delivery of patient-centred care. Nurse managers may
consider the following when selecting a care delivery system for a unit; staff availability, patient
population, organizational goals and unit objectives (Zerwekh, & Garneau, 2017).
I work in a maternity hospital as a nurse-midwife, and we use the total patient care method to
deliver care to our clients. This method is also referred to as case method because patients were
assigned as cases. It is the oldest care delivery, model. It is whereby one nurse provides total
nursing care for one patient throughout the entire working shift. There is no delegation of task.
Therefore, in our facility, one nurse provides holistic care to a group of patients and must
complete the functions of care during the working shift. The functions of care include, needs
assessments, teaching (both patient and the family members) and personal hygiene. This method
is good since it ensures gives the nurse clear responsibility and accountability of the patients
assigned. This promotes continuity of holistic expert nursing care and also make it easier for the
changes in the status of the patient be noticed (Dossey, & Keegan, 2013). The fact that the
patients receive care from one same nurse throughout the entire shift leads to patient’s
satisfaction. Trust is developed between the nurse, patient and family as they work harmoniously
towards achieving some goals. The communication among all the stakeholders also remains
continuous. The stakeholders include the nurse, physicians, other health care staffs, patient and
family.
However, the case method does not work well in some instances, since the nurse spends some
time performing duties which could be done by less skilled personnel cost-effectively. The
method also provides a little allowance for supervision. At times, the nurse may also be
inadequately prepared to deliver total nursing care to the patient, and this is the greatest
disadvantage to the method. This is because the method requires very skilled personnel. Nursing

shortages have also proved the method ineffective since the hospital may end up assigning health
workers such as nurse aides to provide nursing care to the patients (Landry, & Beaulieu, 2013).
Moreover, a high number of patients may lead to one nurse working with more patients which
increases the work overload. Heavy patient load with little supervision is likely to result in
unsafe care. This is because the nurse aims to attend to all the patient, and due to exhaustion may
end up neglecting some of the patient’s needs.
A better delivery system that I can suggest for our facility is Practice partnership model. This
system was introduced in 1989 by Marie Manthey (Wessel et al. 2017). It is whereby a
Registered nurse and assistant such as licensed practice nurse or less experienced registered
nurse agree to work as practice partners. They handle the same group of patients together and
make use of the same working schedule.
Practice partnership: -
The senior staff guides the work of the junior partner on the abilities of the partner. Therefore,
they both deliver care to the patients, but the senior performs selected care responsibilities and
delegate fewer ones to the junior staffs. This model is the modification of the primary nursing
system to make more efficient use of the registered nurse while promoting patient-centred care
(Shipman, & Sinsky, 2013).
The main reason for selecting the method is because it allows for better training and growth of
the better. A nurse working under practice partnership works to their full scope of practice, not
isolated from the title, producing a hierarchy that is flattened within the partnership to maximize
the skills, knowledge expertise and experience of team involved. It is more of a learning
RN Partner
Patients

opportunity for both the registered nurse and the partner. The nurse acts as a trainer and hence
looks forward to being more skilled and well equipped so as to be able to train the partner more
effectively. The method keeps getting more productive with time as the skills keep being better.
The patients, therefore, receive better health care services. The method also ensures safe care
since the nurse only delegates responsibility that are less and can easily be performed by the
partner effectively. The registered nurse performs tasks that require advanced skills. Moreover,
the workload is reduced. Hence the care is delivered even better. Practice partnership is an
efficient and practical way of offering nursing skills of different mixed levels of experiences.
The method is also less expensive to the organization and ensures improved continuity of care.
The partnership may also further involve the physicians, families and other clinicians. This
builds trust, thus enhances confidence and communication (Johnson & Ezekielian, 2014). In the
maternity hospital, the method is even more practical since the partner acts as the assistant. This
is important even during delivery, and it promotes better outcomes.
In conclusion, nurse managers need to promote a working environment that allows for strong and
better relationships among the staffs and the clients. They should implement the changes in
practice that support the partnerships among all care providers, patients and their families. This is
because engaging the patient through the partnership has a positive impact on the patient safety,
satisfaction, quality of care, job fulfilment and outcomes and thus resulting to an increase in the
sense of belonging and well-being. Moreover, patient-focused care is maximized through a
practice partnership since it involves the patient as the central partner. The care is planned at the
bedside considering the patient's needs and establishing personal goals. This results in better
overall health care outcomes within the facility.

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