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Fostering Clinical Reasoning

Fostering Clinical Reasoning. Session objectives. Describe process of clinical reasoning Evaluate importance of clinical reasoning Explore reflective practice. What is clinical reasoning?. Group discussion. What is clinical reasoning?. Collect cues Process the information

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Fostering Clinical Reasoning

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  1. Fostering Clinical Reasoning

  2. Session objectives • Describe process of clinical reasoning • Evaluate importance of clinical reasoning • Explore reflective practice

  3. What is clinical reasoning? • Group discussion

  4. What is clinical reasoning? • Collect cues • Process the information • Come to an understanding • Implement interventions • Evaluate outcomes • Reflection

  5. What is clinical reasoning? • It is about the “WHY”

  6. The importance of clinical reasoning • failure to properly diagnose • failure to institute appropriate treatment • inappropriate management of complication Contemporary learning and teaching approaches do not always facilitate the development of a requisite level of clinical reasoning skills.

  7. The clinical reasoning process with descriptors

  8. Questioning assumptions ‘Theory of situated clinical reasoning’ (McCarthy 2003) • Preconceptions • Assumptions

  9. Types of reasoning • Procedural Reasoning • Earliest and most concrete • If “x” is problem then I need to do “y” • Draw on knowledge to reason • Interactive Reasoning • Focus on clients and ‘humanises” conditions • I need to do “y” but the client would prefer “z” • Conditional Reasoning • Usually requires experience • Reflection on procedural and interactive reasoning • “y” does not work as well in an older population • Pragmatic Reasoning • Considers practical issues • “a” is the best option, but it is too time intensive to be practical • Narrative Reasoning • How we organise our thoughts about the client • Reflection with other health professionals • “x” is not the greatest priority at this point for the clients

  10. Conditional Reasoning • Usually requires experience • Reflection on procedural and interactive reasoning • “y” does not work as well in an older population • Pragmatic Reasoning • Considers practical issues • “a” is the best option, but it is too time intensive to be practical

  11. Narrative Reasoning • ‘Whole story’ • How we organise our thoughts about the client • Reflection with other health professionals • “x” is not the greatest priority at this point for the clients

  12. Facilitating Clinical Reasoning • Use of clinical reasoning cycle and why?? • Encourage reflection and critical thinking

  13. Reflection • Reflection on action (reflect on past experiences) • Reflection in action (reflect during experiences) • Reflection for action (what would be done next time) • The what? • So what? • Now what?

  14. Facilitate and promote effective clinical reasoning • Reflect on new learning Contemplate what you have learnt from this process and what you could have done differently. Next time I would … I should have … If I had … I now understand …

  15. Facilitate and promote effective clinical reasoning • Responses that can encourage clinical reasoning: • Let’s explore this • Let’s think this through • Now let’s consider all the possible options/solutions/outcomes • Show me how you came to that decision • Walk me through your thinking about this

  16. STRATEGIES PROMOTING CRITICAL THINKING • Students can: • Anticipate questions others might ask • Look for flaws in their thinking • Ask someone else to look for flaws in their thinking • Develop "good habits of inquiry" • Develop interpersonal skills • Turn errors into learning opportunities

  17. Activities that promote clinical reasoning skill development in health care • Case presentations • Table top discussions • Grand rounds

  18. Activity • Generate questions to facilitate the different types of reasoning

  19. What questions do you have?

  20. References Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier. Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M. and Silber, J.H. (2003). Educational levels of hospital nurses and surgical patient mortality. JAMA. 290 (12), 1617–1620 Andersen, B. (1991). Mapping the terrain of the discipline. In G. Gray and R. Pratt (eds). Towards a discipline of nursing. (Pp. 95-124) Melbourne: Churchill Livingstone Australian Nursing and Midwifery Council (ANMC,) (2005). National Competency Standards for the Registered Nurse, Retrieved from http://www.anmc.org.au on 28 November 2008. Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, N.J.: Prentice Hall. Bright, D., Walker, W. and Bion, J. (2004). Outreach - a strategy for improving the care of the acutely ill hospitalized patient. Critical Care Medicine, 8(1), pg. 33-40. Ericsson,K., Whyte, A. and Ward. J. (2007). Expert performance in nursing: reviewing research on expertise in nursing within the framework of the expert-performance approach. Advances in Nursing Science, 30 (1), 58-71. Higuchi Smith, K.. and Donald, J. (2002).Thinking processes used by nurses in clinical decision-making. Journal of Nursing Education, 41(4), 145–154.

  21. References Incident Management in the NSW Public Health System 2007 July to December. (2008). Clinical Excellence Commission. NSW Health. Clinical reasoning Instructors resources, School of Nursing and Midwifery, Faculty of Health University of Newcastle 2009 Hoffman, K. (2007).Unpublished PhD thesis, A comparison of decision-making by “expert” and “novice” nurses in the clinical setting, monitoring patient haemodynamic status post abdominal aortic aneurysm surgery. University of Technology, Sydney. Kamin, C., O‟Sullivan, P., Deterding, R. and Younger, D. (2003). A comparison of critical thinking in groups of third-year medical students in text, video and virtual case modalities. Academy of Medicine, 78(2), 204–211. Kraischsk, M. and Anthony, M. (2001) Benefits and outcomes of staff nurses‟ participation in decision-making. The Journal of Nursing Administration, 31(1), 16–23. Lauri, S., Salantera, S., Chalmers, K., Ekman, S., Kim, H., Hesook, S., Kapelli, S. and MacLeod, M. (2001). An exploratory study of clinical decision-making in five countries. Image–Journal of Nursing Scholarship. 33(1), 83–90. McCarthy, M. 2003. Detecting Acute Confusion in Older Adults: Comparing Clinical Reasoning of Nurses Working in Acute, Long-Term, and Community Health Care Environments. Research in Nursing and Health 26, 203–212 15

  22. References McCaffery, M., Rolling Ferrell, B. and Paseo, C. (2000). Nurses’ personal opinions about patients pain and their effect on recorded assessments and titration of opioid doses. Pain Management Nursing, 1(3), 79-87. Rubenfeld, M. and Scheffer,B. (2006). Critical Thinking Tactics for Nurses. Boston: Jones and Bartlett Scheffer, B. and Rubenfeld, M. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, (39), 352-359 Schön, d.A. (1983). The reflective practitioner: How professionals think in action. New-York: Basic Books. State Government of Victoria, (2007). A ‘critical’ reflection framework. Retrieved from http://www.education.vic.gov.au/Documents/childhood/professionals/support/reffram.pdf University of Western Ontario (2012). Understanding and fostering clinical reasoning. Retrieved from https://owl.uwo.ca/portal/site/edc3ab16-818e-4173-88f4-e24cad89cf4b/page/02cf08b8-201b-4b5a-93e9-f9a45043b9cf Wilson, R. (1995). The Quality in Australian Health Care Study. Medical Journal of Australia, (163), 458-471.

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