Critical Care Orientation and the Importance of Developing Clinical Reasoning - Research Proposal Example

? I. PROBLEM: Registered nurses that transition/orientate into an intensive care unit do not receive enough orientation to develop the ability to clinically reason and key competencies/essentials needed to practice safely in critical care. Nursing education has understood the value of critical thinking as an essential nursing skill, throughout all the incarnations by which critical thinking has itself been defined over the course of the 19th and 20th centuries. The method by which critical thinking is defined will control how it is taught to the next generation, and to what standard of clinical excellence nurses will be held accountable. Critical thinking itself may be thought of in nebulous terms amongst nursing students. It is important not to distill the critical thought process as it pertains to clinical endeavors with simple, smart sounding labels, like wisdom or 'know-how'. II. DEFINITION OF CLINICAL REASONING Clinical reasoning must be more than a simple application of theory, because patients are individuals – and the therapist/nurse must adapt a treatment plan towards the individual, personal needs of each patient. Clinical reasoning under the perspective of certain researchers becomes a largely tacit phenomenon (Matingly, 1991). Our understanding of critical thinking as it pertains to the clinical setting has matured over the course of the decades. There are several key items for critical thinking for the professional to consider. The American Philosophical Association (APA) has defined critical thinking as: '...purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations on which judgment is based' (APA, 1990). But there are other professional bodies that have also required a critical thinking mandate be added to curriculum, in many fields – not just nursing. But precisely what that means, and how those decisions are to be rendered is still worthy of discussion. Clinical reasoning is not limited simply to the documentation of the patient's history; it is ongoing throughout physical examinations and the use of imaging technologies, as well as laboratory testing. It continues before, during, and after the initial diagnosis (Wiener et al. 1995). In the dimension of nursing and clinical responsibility, critical thinking is the foundation of quality care, as well as professional standards of accountability. The professional must consciously cultivate the characteristics of efficient clinical mindset. This includes the ability to place events within the proper overall context, self-confidence in the nurse's ability to perform the necessary job functions, as well as a certain flexibility. The nurse must also cultivate creativity when time, resources, or both are limited, as well as a certain intellectual curiosity, leading to a state of mind that is always willing to learn more and adapt novel technologies and clinical modalities when and where they will prove effective in the practice of the individual medical professional. This dovetails with the ability for critical reflection on one's self, and on one's job performance. The nurse must be analytical in regards to new information, and the requirements with a willingness to seek out and verify potentially useful discoveries; vetting innovations for their clinical utility, as well as, ultimately, a long-suffering perseverance against adversity. More recently a comprehensive definition was also provided by the National League for Nursing Accreditation Commission: The deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research (NLNAC, 2007, p. 8). How then are we able to determine what thinking processes meet the critical thinking standard essential for the clinical dimension? In what way is critical thinking different from ethics, or directed self reflection? But as clinical modalities available to hospitals and the medical professionals begin to increase greater efficiency at the evaluation of information, practices become a relevant issue. There are issues involving the evaluation of research, and the complexity of patient care for which higher level decision-making will be required in the future, if not this very moment in the modern medical field. It is nurses that must learn to apply critical thinking towards the application, and evaluation of knowledge to better assess patient problems, thereby guiding the clinical judgment processes to affect a positive outcome for all patients. Still, an exploration of the topic is essential – because of the danger inherent in students adopting critical thinking as a catchall for different modes of thought. This leads to misunderstandings concerning the application and value of different levels of self reflection, and clinical evaluation. III. THEORETICAL FOUNDATION While critical thinking is essential to the clinical profession, it is certainly not the only reasoning capability. Other strategies are integral to the critical thinking process; deduction, analytical acumen, and the efficient assimilation of data are also necessary. In the end, when moving from novice to expert, as Benner describes it. Ultimately, there is no substitute for experience. Benner describes the limitations in providing high-quality care, where the abilities of the nurse/clinician to provide optimal treatment is typically limited by the lack of experience (Benner et al. 2008). For the student, some researchers make the suggestion that as a method of sharpening clinical reasoning aptitude, a good strategy might be to see as many different patients as possible – but with the same pathology (Cohn, 1989). Clinical-based thinking can be distinguished as a practice-based method of reasoning that requires a method comprehensive background of scientific and experiential knowledge concurrent with the latest research. It also requires practical attitude to discern the effectiveness of the evidence underlying pertinent scientific knowledge, ways to integrate it into the nurses' own professional practice, and how it applies to the situation of a given patient. With this method, the clinician considers the patient’s most probable prognosis, their personal concerns, and their particular sensitivities, both in terms of nosocomial risk factors that their clinical status might predispose them to. Individual vulnerabilities must be considered, such as known allergies to various treatment modalities – such as penicillin. In addition to their emotional sensitivities – vital to proper bedside manner, an integral component of a positive patient outcomes. when forming clinical conclusions. The nurse must learn to integrate a variety of experiences and medical data into the form of clinical reasoning that is essential to success as a medical professional. There is a social dynamic involved, both in the interactions with doctors, other nurses, as well as maintaining a proper bedside manner. Some might argue that the social dimension is less essential than the certainties of clinical logic, but for career success and hospital efficiency, the interpersonal dimensions must not be neglected. To an extent, clinical reasoning must always take into consideration a numerical, cost benefit analysis. But nurses and other clinicians must develop ways of factoring into the equation. The outcome benefits of the social dimension. Educators, especially, in fields of clinical relevance have begun to take this necessity seriously (Sullivan, 2005; Benner & Hooper-Kyriakidis, 1999). Many sources agree that the nurse in the clinical setting must develop an emotional perception enabling the professional to become attuned to the dynamics of emotional engagement with an understanding of their impact towards the clinical setting and proper engagement in the emotional lives of patients to the extent that it assists recovery (Chan, 2005; Halpern, 2001). In a pure sense, critical thinking/reflection demands that the thinker examine the fundamental assumptions that underlie assertions, ideas that are thought of as common sense, and, where possible, even the material facts of a given situational premise. Everything that is thought to be true must be observed under a harsh light, and dispassionately scrutinized for flaws, or holes. Underlying ideology must be stressed by critical review to see if it will break under logical scrutiny. These tenants are essential to the scientific method, and thus to any application of scientific medicine. However, even with critical review, there must be a cold evaluation. Critical analysis of known facts can bog down the necessary business of the professional. Clearly, the doctor cannot question the underlying facts of human anatomy, with a critical emphasis towards disproving them. The clinician must bring all his mental faculties to bear in situations in which standard treatment modalities appear to be insufficient to preserve the life, and health of the patient. When the outcome is uncertain and the consequences severe, the clinical nurse must identify and harshly analyze all assumptions of medical relevance. The fundamentals of the human circulatory system have been known since the 17th century (Wheatley, 1999) and thus should not be questioned during any routine process. Those questions are for the medical researchers, and there is still much to be learned. Using the example of the circulatory system, such as the differences in functionality between various human population groups, as well as the functioning, and this function produced by excess cholesterol within blood vessels, it can be stated that much work still needs to be done concerning those subjects. Another component of critical thinking is the comprehension of the fine distinction between the technical process by which objects or operations are conducted, and the efficient professional practice pertaining to interaction with both colleagues and clients/patients. Greek philosophers defined this distinction as the difference between techne and phronesis (Barnes, 1984). Techne can be defined as the activity of producing outcomes, or constructing objects. The producer, or a builder, defines the process by gaining mastery over the techniques involved in the technical production (Dunne, 1993). This can also be referred to as procedural reasoning which is the most concrete, the most easily communicated by standardized curriculum, and with the onset of the scientific revolution generally regarded as being more important. Such tasks are problem identification and the planning out of goals (Fleming, 1991). Phronesis becomes an evolution of understanding that a professional attains over the process of execution leading to a more nuanced understanding of the underlying factors of the profession (Dunne, 1993). Phronesis is experiential; techne/knowledge is practical and replicable. In our Western tradition, there may be a tendency to devalue the more intuitive, experience-dependent value of phronesis. A balance between these two conceptions is an integral component of the development of critical thinking, most essential in the nursing field. This will allow the nursing professional to meet the needs of patients on their own terms, using methods that will be most impactful towards a beneficial outcome in each clinical situation. Scheffer adopts the following principles as necessary to the theoretical foundation of critical thinking: fundamental curiosity, analytical ability, application of standards, factual discrimination, and logical reasoning (Scheffer & Rubenfeld, 2000). Something that many practitioners learned at the onset of experience is that while vast quantities of essential information are available through the technical procedures of laboratory testing, and diagnostic machinery, it requires wisdom/phronesis in many cases to simply sift through the available data. Experience is needed to properly identify which medical results arriving from didactic testing modalities are actually useful. The clinician must be able to decide from the data which course to take, especially in situations with complex illnesses accompanied by dangerous co-morbidities. Many investigators agree and adopt similar strategies (MacIntyre, 1981; Gadamer, 1975). Invariably, most investigators will endeavor to develop a comprehensive strategy that will unify the two types of knowledge. Several researchers have pioneered the concept of what they term 'Narrative reasoning' where the data, relevant patient details, and social interactions are organized in similar fashion to a descriptive account, as a means of uniting the disparate strains of knowledge (Alsop & Ryan 1996; McKay & Ryan 1995). IV. DEVELOPING CLINICAL REASONING Linda believed that she was being kind to the child by telling him and his mother that he was such a handsome boy. She did not understand why the mother suddenly became so worried, a cloud seemed to fall over her face. It was only later that the head nurse took her aside and asked her if she had any idea why the boy's mother, Mrs. Gonzalez, had checked him out of the hospital early that she became concerned. She would find her friend Cindy, the older nurse had a great deal of insight – not only concerning medical issues and test results, but also concerning what the patients were thinking and feeling. It was vital that Linda attempt to influence the mother to stay, if at all possible – they needed to keep the boy under observation to make sure that his infection did not return. Eventually Cindy was able to find out that the Gonzales family came from a remote, south American village that believed in the evil eye. By complementing the child and touching him up on his head Linda had inadvertently invited misfortune upon the family – so went the beliefs of their native culture. Linda raised an eyebrow in disbelief, but Cindy assured her that in their value system these beliefs were very important. Just a simple, small gesture could make a difference in whether this patient would be allowed to receive the care that the hospital could provide. The instances in which social factors can impede or prevent the proper application of medical technology are multi-various and can be subtle. A well-developed understanding, as the professional progresses from novice to expert, can also lead to a predictive capability to intuit likely patient outcomes apart from - or in absence of - the medical data, as a valuable supplement. The term “Clinical grasp” can describe an active form of clinical inquiry. Clinical grasp starts with perceptive insight and progresses to problem identification and clinical judgment throughout time concerning the shifting medical conditions of specific patients. Some researchers describe the clinicians efforts to reach a state of clinical optimization, or grasp (Chan, 2005). Clinical Grasp can be described as: Achieving qualitative distinctions, such as those that can only be reached within a particular historical context. The nurse/clinician must be aware of changing cues from the patient that might signify transitions in medical status. Both in terms of patient behavior and subtle, external cues such as the color and turgor of skin and wounds. Investigative interest. It means keeping track of the development of the patient's condition and identifying cues in the patient's responses that may indicate pending issues, such as unfavorable drug interactions. Identification of changing clinical priorities. Changes in signs and symptoms can signal deterioration of the patient's medical condition. The same symptoms during curative treatment can have different meanings, and thus different consequences in a the transition to supportive/palliative care. Medical knowledge of specific patient populations. As the above case demonstrates, social?cultural factors have the potential to influence not only the effectiveness of care, but whether the family may attempt to interfere in care, resulting in low compliance with medically necessary treatment modalities. The nurse/clinician must cultivate an understanding of underlying background issues to ensure proper care. Furthermore, different ethnic populations may have higher predilections for conditions such as diabetes, for instance, or various forms of cancer (Chan, 2005). In addition, a vital tool to sharpening clinical reasoning would be the related principle of Clinical Forethought. Forethought is more deliberate, and less tacit than the 'riding the bike' style of clinical reasoning espoused by many researchers. It entails active participation in projections of the future; “future-think”, it might be termed; the focused direction of reason and experience towards the prediction of likely events to come relevant to the patient (Benner et al. 2008). Young nurses may not naturally conceive of habits and preparations that seasoned veterans eventually adopt to the point that they become second-hand. It requires conscious effort to analyze the facts at hand and project outcomes forward, in the absence of the needed experience to ease the path to such understanding. Is all the equipment that the patient will need during surgical recovery available, convenient and ready for use, or surgical insertion? Is all the equipment for dialysis, catheterization, or phlebotomy prepared in the right location, at the right amounts? Is there any additional equipment requiring special permissions or preparations that the patient will need? And have all those permissions and requisitions been secured prior to the surgical recovery? The new practitioner must work harder to overcome these challenges before optimal habits develop. V. SUMMARY. In essence, the study of clinical reasoning distinguishes between regimented technical knowledge of how to do, or create, in a way that is repeatable and teachable in textbooks, with a more intuitive knowledge. Efficiency as a clinician requires not only aptitude towards the application of technical knowledge and medical research; it also requires experiential wisdom to know the most effective way to employ the data and equipment available. Also vital are the social factors that can affect patient compliance with treatment regimen, which the experienced nurse must learn to predict and avert. As well as the understanding of subtle, sometimes spoken, sometimes unspoken clinical cues that may signal changes in patient medical status. The two principles of technical and experiential expertise must be united to achieve the most effective, efficient clinical thinking for the nurse/clinician and for the patient's benefit. REFERENCES Alsop, & Ryan. (1996). Making the Most of Fieldwork Education: A Practical Approach. New York, NY: Chapman & Hall. American Philosophical Association. (1990). Critical thinking: a statement of expert consensus for purposes of educational assessment and instruction. ERIC document, ED 315-423, 1990. Barnes, J. A. (1984). Metaphysics, Nicomachean ethics, politics, rhetoric and posterior analytics. In: Barnes J, ed. The complete works of Aristotle. Revised Oxford translation in two volumes. Princeton, NJ: Princeton University Press (Bollingen Series). Benner P, Hooper-Kyriakidis P, & Stannard D. (1999). Clinical wisdom and interventions in critical care. A thinking in-action approach. Philadelphia: WB Saunders; 1999. Benner, P, Hughes, R. G., & Sutphen, M. (2008). 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Sullivan, W. (2005). Work and integrity: the crisis and promise of professionalism in America. San Francisco: Jossey-Bass. Weiner, S. L., & Higgs, J. J. M. (1995). Reviews and Notes: Clinical Reasoning in the Health Professions. Boston: Butterworth-Heinemann; 1995. ISBN 750607874. Wheatley, D. N. (1999). On the vital role of fluid movement in organisms and cells: a brief historical account from Harvey to Coulson, extending the hypothesis of circulation. Med Hypotheses, 1999;52(4):275-84. Read More