There are literally thousands of clinical practice guidelines (just check out the National Guideline Clearinghouse website:
), ranging from treatment of acute respiratory failure to managing arterial hypertension. Guidelines play a critical role in helping maintain high standards of care by communicating a summary of the developing knowledge around particular issues so care practices better follow advancements in our science. Guidelines are intended to serve as a reference point for clinicians to provide standardized care for any given problem. At the same time, however, our facilities and health care systems are promoting individualized, or person-centered, care ideals, suggesting that care decisions be made based on the priorities and preferences of the individual receiving care. Standardizing care and individualizing care may seem in opposition to one another. An artful balancing act is required by nurses who successfully infuse individualized care ideals into guideline-based care.
Consider the following example: A 98-year-old man had a 15-year history of taking routine ibuprofen (Advil® and others) every 8 hours for arthritis pain. During those 15 years, he golfed, played pool, and had a girlfriend he visited three to four times per year when he traveled to Florida. After an increased history of falls with no broken bones, he entered a nursing home for short-term muscle-strengthening rehabilitation. He was dead in 8 weeks. On entering the nursing home and following recommendations of important guidelines, his routine ibuprofen was stopped due to his advanced age and concerns over kidney function. His family reported that he “begged” not to be moved in bed, cried in pain when moved, and deteriorated rapidly from arthritis pain.
The balancing act necessary in this example highlights the place for the “art” of nursing. In this particular case, years of daily ibuprofen use may have resulted in damage to his kidneys (analgesic nephropathy) and contributed to his death. At the same time, the ibuprofen had been providing sufficient relief for years, allowing him to maintain an enjoyable, active lifestyle. Given the history of good pain control, maintaining this treatment may have been the best approach. Either way, as these two seemingly opposing realities met, the need for an integration of individualized care with guideline-based care was needed in order for this man’s preferences to be honored. As it was, his quality of life was significantly altered by following the guideline rather than making a treatment decision based on his individual circumstances and response to ongoing treatment.
Guidelines serve as the overarching standard—the proverbial 30,000-foot view—but the individual in front of you—at street level—has all the complexities and intricacies accumulated over a lifetime. The challenge for the artful nurse is to provide nursing care with knowledge deeply grounded in science while serving as a collaborative advocate for the individual’s voiced preferences and priorities. Meeting this challenge requires us to move beyond simply implementing a guideline to an ongoing assessment of the individual’s level of understanding as we teach about care and treatment options and discuss the potential consequences of each. This requires that we invest in learning about the individual’s personal goals, especially those related to quality of life. In other words, to incorporate guideline-based care into individualized care, we must also pursue knowledge deeply grounded in the person in front of us. We must communicate not only the risks and benefits of care options but know the person well enough to discuss the risks and benefits as they apply to their unique situation. Interpersonal skills of negotiation, empathy, diplomacy, and patience are tools used by the artful nurse. And, when used successfully, we communicate a desire for collaboration, value the person’s individuality, and empower the person to maintain control of decisions that matter in his or her life (Gibson & Ferrini, 2010).
Individuals come with their own complexities, and so do the realities of nursing care. What happens when people can no longer participate in care decisions? The truth is that many people we work with are capable of making informed decisions about their health care, especially when that information is provided in a way that helps them think about the effect on the quality, or perhaps the longevity, of their lives. Our responsibility is to make regular efforts toward opening the collaborative dialogue and assessing their capacity. On the other hand, there are people we care for who no longer have this capacity. In these cases, we often need to defer to close family members and friends who can make decisions on behalf of the person, based on the individual’s longstanding values and preferences.
Further complexity occurs when the decision made by the informed individual is in contrast to the guideline. What is our role then? When the role of educating and informing is done, our responsibility is to respect the person’s decision and, if necessary, to become an advocate in support of that decision, even if it conflicts with a guideline or the larger health care team’s recommendations. The “art” in these complex situations does not always stay in the lines, nor should there be only one artist. Thus, seeking consultation from experienced colleagues is invaluable in these situations.
The artful nurse continues to acquire skills both through practicing at the bedside and through remaining knowledgeable about relevant guidelines. In addition to the knowledge needed about the individual, the nurse must also carefully select high-quality guidelines, based on standards set by the Institute of Medicine (IOM, 2011). These guidelines can and should provide the foundation for that bedside practice. Choosing trustworthy guidelines requires knowledge of the development process of the guideline, which should include patient and consumer representation in order to broadly capture preferences and priorities of key affected groups (IOM, 2011). Guideline development should also include appropriate interdisciplinary (e.g., nursing) representation and be based on an explicit and transparent process to improve evaluation and selection by end users of the guidelines (IOM, 2011). Clinical practice guidelines and individualized care are not at odds, but integrating the two requires skillfully applied knowledge that honors individual choices.
Kristen L. Swafford, PhD, CNS, RN
Oregon Health and Science University
School of Nursing
National Nursing Home Pain