Reflective Decision Making Using Clinical Reasoning Model - Case Study Example

Reflective decision making using clinical reasoning model Introduction/ Background Clinical situations require nurses to make critical decisions that could affect the health and overall well-being of patients. In acute health care settings that are characterised by patients with complex health problems, nurses are required to regularly make clinical decisions on how best to address patients’ symptoms and warning signs as they emerge (Bucknall, 2000; Thompson et al., 2004). In order for nurses to make valid decisions on how to address patients’ health problems, they must engage in clinical reasoning (Aiken et al., 2003; Banning, 2008). Clinical reasoning can be described as the process through which nurses observe and collect cues, process information, analyse and understand patients’ health problems, plan and execute suitable interventions, evaluate the realised outcomes and subsequently reflect on what they have learned from the situation. In order for patients to realise positive health outcomes, it is important for nurses to exercise effective clinical reasoning. Effective clinical reasoning is dependent on the ability of nurses to identify the right cues and implement the right intervention for the right patient at the right time and for the right reasons (Levett-Jones et al., 2010). This paper seeks to critically examine the process of clinical reasoning and decision making cycle in a particular clinical scenario that I was involved in. Firstly, using the clinical reasoning model this paper will explore how decisions were made in the clinical scenario I was involved in and some of the key influencing factors of those decisions. It will also evaluate the effectiveness of the actions taken and identify the errors or assumptions that may have influenced clinical decisions in that scenario. Lastly, this paper will incorporate a personal reflection on the clinical scenario and offer recommendations for improvement in future clinical decision making and practice. Clinical Reasoning The clinical scenario that I was involved in revolved around Mr Smith, a 68 years old patient in a nursing home suffering from chest pains and impaired cognitive function. On a particular day, Mr Smith complained of severe chest pains, he looked restless and agitated. As a student nurse, it was important to engage in effective clinical reasoning. Needleman et al. (2001), observe that nurses’ clinical reasoning skills play a critical role in determining the health outcomes of patients. It is through effective clinical reasoning that nurses are able to properly diagnose patients’ condition, institute appropriate treatment and management of emerging complications (Tanner, 2006; Levett-Jones, 2013). Therefore, in order to improve Mr. Smith’s health outcomes, it was important to engage in effective clinical reasoning. I foremost began by considering Mr. Smith’s situation (Levett-Jones, 2013). I took into consideration, his complaint about experiencing severe chest pains and the fact that he was able to identify the exact location where he was feeling the pain and unable to explain the quality or severity of his chest pain. I also took into account his behaviour and noticed that he was very restless and agitated than usual. By considering his situation, I deduced that there was a high probability that Mr. Smith’s complaints were genuine health concerns that required serious clinical attention and intervention. As a result, I decided to inform the Registered Nurse (RN) about the patient’s situation. My decision to inform the RN about the patients’ condition was largely influenced by the clinical risk signs that the patient was exhibiting. The fact that he was restless and agitated than usual and was able to accurately locate where he was feeling the pain, signaled that Mr. Smith was a clinically at risk patient. Thompson et al. (2008) recommends that when deciding what action to take (such as informing an RN or calling a medical emergency team) during a clinical situation, nurses must estimate the amount of clinical risk portrayed by patients. Personally, I decided to inform the RN about the patient’s condition, after evaluating the patient’s situation and noticing that the signs he was portraying were unusual and critical. After informing the RN about the patients’ complaints and the signs he was exhibiting, I received a nonchalant response. As a nursing student, I decided to further engage in clinical reasoning by collecting cues in order together evidence that will support the implementation of a suitable clinical intervention that will improve Mr. Smith’s health condition. According to Elstein & Bordage (1991) and Tanner (2006), collecting cues is one of the fundamental processes of clinical reasoning. Generally, cues are the identifiable psychosocial and physiological changes that a patient experiences. They can be identified through assessment and examining the patients’ medical history. Furthermore, cues may be collected based on certain philosophical beliefs and specific body of knowledge. They may also be collected by taking into account the surrounding clinical situation and the context of care. Nonetheless, O’Neill et al. (2005) observes that the collection of cue can be influenced by factors such as confidence, anxiety and the working knowledge or expertise of the clinician involved. Personally, I believe that previous training played a significant role determining how I collected the cues. Moreover, this process was guided by the standards set in the Australian Nursing & Midwifery(ANM) guidelines (2013) which require that nursing interventions should be implemented after a systematic, accurate and comprehensive assessment of a wide range of evidence pertaining to a patient’s condition. Therefore, rather than solely relying on information about the patients’ past behaviour like the RN did, I decided to collect cues by examining a variety of evidence pertaining to Mr Smith’s condition. I reviewed the patient’s medical history, progress notes and previous medical and nursing assessments. By examining these sources, I was able to establish that, Mr. Smith has a history of angina and stroke which permanently affected his cognitive functions, mobility and impaired his communication. I also reviewed his medical chart and established that he was under cardiac medication and Glyceryl Trinitrate (GTN) Nitrolingual pump spray was ordered. The patients’ medical history and previous clinical assessments also revealed that the patient exhibited unusual behavioural patterns such as excessive use of his buzzer to call for nurses’ attention and regularly complaining of pain without effectively describing and locating where he is experiencing the pain. This in turn influenced the perception of nurses regarding his health condition and caused them to believe that all the signs exhibited by Mr. Smith stem from behavioural issues. Following the cue collection process, I analysed and processed the information gathered and compared it with the recent signs that the patient was exhibiting. I noticed that unlike the previous cases where Mr. Smith complained of pain but was not able to explain or accurately show where he was experiencing pain, in this instance he was able to localise his pain accurately by pointing to his chest when asked where he was feeling pain. These cues raised my concerns even more about Mr. Smith’s health condition. Although the cue collection process provided invaluable insight on the patients’ condition, the information was not conclusive thus it was difficult to identify exactly what was ailing the patient and determine suitable action or intervention to implement in order to address the patient’s situation (Alfaro-LeFevre, 2009). In order to come up with conclusive evidence on the underlying causes of Mr. Smith’s chest pain, I decided to take action by conducting further assessment using Electrocardiograph (ECG) so as to identify any abnormalities. However, it later came to my attention that the nursing center did not have an ECG machine. The lack of this equipment impeded on my clinical reasoning process since it was difficult to make any decisions when uncertain about the underlying cause of the patient’s chest pain and the suitable intervention that can be implemented in order to improve the patient’s condition. After sometime, Mr Smith begun to sweat profusely and it became apparent that he was experiencing some discomfort due to the pain in his chest. At this point the only option left was to communicate to the RN about the patient’s condition with the hope that she will take action. Levett-Jones et al. (2010) observes that, sometimes the ‘right action’ that nurses can take in a clinical situation is to relay information about a patient’s deteriorating condition to their seniors. They further note that nursing students should be skilled in communicating with senior healthcare staff so that they can signal the need for immediate action in addressing signals or risks exhibited by a patient. A considerable number of studies have established that effective communication within health care settings significantly contribute to quality and safe healthcare delivery (Mikos, 2007; Levett-Jones et al., 2010; Levett-Jones, 2013). The ANMC guidelines (2006) also require that effective communication should be exercised within the clinical settings so as to facilitate the provision of quality care. However, in my case communicating to the RN regarding the need for immediate action in order to address Mr Smith’s condition seemed to be ineffective. Even after communicating to the RN for the second time about Mr Smith’s condition she failed to take action. Consequently, Mr Smith’s condition deteriorated. I believe that Mr. Smith’s condition could have been prevented from deteriorating, if the RN exercised effective clinical reasoning by identifying the right cues and implementing the right intervention at the right time (Levett-Jones et al., 2010). As a student nurse with limited mandate to make and implement clinical decisions, I believe that I acted accordingly. The deterioration of Mr. Smith’s health condition can be largely attributed to the RN’s failure to exercise effective clinical reasoning. Mr. Smith condition could have been prevented from deteriorating if the RN would have collected accurate cues through clinical and medical assessments, processed information and implement a suitable intervention. However, the RN’s cue acquisition was marred by assumptions and errors. It is apparent that based on previous behaviour, the RN had formed preconceived ideas about Mr. Smith and labeled him as a difficult patient. Levett-Jones (2013) identify preconceived ideas, assumptions, stereotypes and biases as major impediment to effective problem-solving and decision making. Moreover, McCarthy’s (2003) theory of clinical reasoning provides insights on how nurse’s personal beliefs and assumptions particularly about ageing influence how they provide care to older patients. McCarthy notes that, nurses’ assumption and belief condition they way in which they judge and respond to patients with acute conditions. In the case of Mr. Smith, it is evident that the RN had established preconceived ideas and assumptions that the symptoms he exhibited stemmed from behavioural issues rather than actual clinical or medical problems. In essence, the RN committed clinical reasoning errors such as attribution error, ascertainment bias and unpacking principle error (Levett-Jones et al., 2010; Levett-Jones, 2013).These errors in turn influenced her decision not to conduct a clinical assessment or implement any intervention in order to address the patients’ complaints. By so doing she failed to exercise her duty of care as stipulated under the ANMC guidelines (ANMC, 2006). Refflective Practice The clinical scenario revolving around Mr Smith provided invaluable insight on the role of clinical reasoning and decision making in clinical and professional practice. As a nurse student aspiring to become an effective RN in future, I was able to draw several lessons from this scenario that I believe will shape my professional practice in future. Reflecting back on my involvement in delivering care to Mr. Smith, I believe that although his condition deteriorated, I exercised effective clinical reasoning. I employed my clinical reasoning skills based on the ANMC guidelines and the clinical reasoning cycle. For instance, I collected cues by carefully, reviewing the patients’ medical history and undertaking patient assessment. After carefully assessing and processing the information collected, I effectively communicated to the RN regarding my concerns about the risk signs Mr. Smith was exhibiting (ANMC, 2006; Levett-Jones et al., 2010; Levett-Jones, 2013). However, the effectiveness of this clinical reasoning process was impeded on by the lack of required equipment to assess the underlying cause of the patient’s chest pains, inadequate staffing and clinical reasoning errors. From this scenario, I was able to establish that clinical equipments, adequate staff support and effective clinical reasoning play a critical role in determining the quality of healthcare delivery and the overall health outcomes realised by patients. For example, the lack of ECG machine in the nursing center made it difficult to conduct a clinical assessment on the patient thus it was difficult to diagnose the patient’s problem or determine suitable intervention that would help improve the patient’s health outcomes. Although the ECG machine was not present, I believe that rather than ending the cue collection process, I would have done better by conducting further research so as to find evidence that would help assess and identify the patient’s problem (Tanner, 2006; Hoffman et al., 2009). Moreover, inadequate staffing put a lot of stress and strain on the RN by overwhelming her with excess responsibilities and workload. This might have influenced her decision not to take any nursing action in order to address Mr. Smith’s health complaints. Nevertheless, I believe that the RN could have handled the situation better by prioritising her workload from most important to less important and delegating less important tasks to other clinical staff so that she can focus on assessing and implementing suitable clinical interventions to patients in critical condition such as Mr. Smith. From this scenario, I learnt the importance of prioritising and delegating work. I intend to apply these principles in my future clinical and professional practice as an RN (Ruff, 2011; LaCharity et al., 2010). One of the core lessons, drawn from this scenario revolves around the influence that assumptions and errors have on clinical reasoning and decision making. I believe that my clinical reasoning and decision making in this scenario was solely founded on knowledge from previous clinical training and assessment of evidence from valid sources such as patient’s medical history, progress notes and previous medical and nursing assessments. Conversely, I was able to deduce that the RN’s clinical reasoning and decision making in this scenario was marred by preconceived ideas and assumptions that the symptoms Mr Smith exhibited stemmed from behavioural issues rather than actual clinical or medical problems. Consequently, the RN failed to conduct a clinical assessment or implement any intervention in order to address the patients’ complaints. Personally, I find that this situation highlights the need for clinicians to base their clinical judgment solely on evidence from clinical assessments and constantly reexamine their beliefs and assumptions especially about delivering care to older patients (Alfaro-LeFevre, 2009; Levett-Jones et al., 2010; Levett-Jones, 2013). Conclusion This paper has critically examined the process of clinical reasoning and decision making cycle in a clinical scenario revolving around Mr Smith, a 68 years old patient in a nursing home suffering from chest pains and impaired cognitive function. Using a clinical reasoning model, it has explored how decisions were made in the clinical scenario and some of the key influencing factors of those decisions. The findings of this paper show that, effective clinical reasoning is dependent on the ability of nurses to identify the right cues and implement the right intervention at the right time. 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