Justifications for linical Reasoning - Article Example

Mr James smith, a fifty two years old patient, a green grocer with a wife and two children who are grown up finds himself in clinical condition that calls for proper diagnosis and intervention. His clinical condition report since he was young indicate several numerous injuries he developed as a result of rugby for which he was a player. He not only suffered the injuries but when a head and suffered from arthritis in both of his knees. He is a chain smoker and takes a minimum of 25 cigarettes per day. As a result of this, he seems to have developed a chronic obstruction of the pulmonary disease which is the inflammation of lungs and frequently suffers from breathing difficulties and heart problems. Salbutamol and Atrovent inhalants have been prescribed for him and they seem to have very little effect since he has the persistent coughs caused by accumulation of mucus in the bronchial tubes. He continuous to suffer incessantly because he also has hypertension and hypercholesterolemia which have symptoms of difficulty in breathing and continued heart failure. He is on medication that calls for use of very strong drugs for proper heart functioning. Far from the heart problem, he is experiencing chest pains. Mr Smith is a critical care patient and he faints and diagnosis indicates heart failure due to secondary COPD. He has low spirit, and lacks mobility with painful joints. The admitting Regular Nurse indicate that his O2 sits at 88%, the doctor in the emergency department prescribes 24% of O2 via nasal prong. He is also constantly feeling a red pressure under coccx, and heels. But still experiences the shortness of breath and with decreased chest expansion. This is a complex situation that when not handled properly can lead to death of the patient. It is case that needs to be handled by a multi-disciplinary team and proper communication has to be put in place. In accordance safety in clinical practise, clinical reasoning has to be well coordinated and the flow of response will have to be maintained. Correct communication cannot be applied independently; some reasoning has to be applied to be able to maintain the flow of a well coordinated response. It is that process through which knowledge already acquired can be put into practice. It is the expertise that is wanted in any clinical situation for developing solutions to a wide array of problems. Nursing concepts, processes and strategies have been developed to enhance cognition, thinking and possibly the meta-cognition. As a fact, all this possess their own merits and demerits and hence constant research and training needs to be carried out to elevate the standards of practice by physicians and the nurses. Quality of service should be uncompromised at all level and that should not be contested at any level of reasoning. Clinical reasoning, clinical judgement, problem solving, decision making and creative and critical thinking all apply to the same kind of description and such a case of Mr Smith require this level of intervention because Arthritis, hypertension, and COPD seem to share common symptoms and signs that should be well distinguished professionally.. Models of clinical reasoning have been developed to illustrate the various on goings that are cyclical in attributes in the clinical encounters. Rights in clinical reasoning create a concise environment that ought to be adapted especially for complex situation. However, they should be adhered to at all times because of their relevance and association with evaluation and reflection before setting up interventions. Clinical reasoning has eight steps that are very necessary. However they seem to possess unclear boundaries between each other. This include; looking, collecting, processing, deciding, planning, acting, evaluation and finally reflecting. It is an indication of the dynamism that is required in clinical reasoning which may require combining one or two of each of the elements before making radical decisions and taking actions. Justifications for clinical reasoning Mortality of patients that experience a hospital acquired complication has been indicated to be directly correlated to the quality of the nursing care and nursing skills. The top three outcomes of failure to rescue have been attributed to misdiagnosis, failure to administer the proper treatment and the inappropriate management of complications. Mr Smith may be a victim of such like practice, the Regular nurse wants a probe into his pharmaceutical review. This can be reduced by imparting proper clinical reasoning skills. Nursing practice demands the engagement of a multiple CR elements fo each individual patient under their care. Experts seem to develop instinctive methods because of their diverse knowledge and skill along their line of specialisation. It is not easy for them to verbalise their thinking and explain their cognitive process. Repeated practise has been shown to have a role in a faster memory retrieval of information and skills. This develops into an unconscious intuitive reasoning. Hence communication and clinical reasoning are essential for medical practitioners. Clinical reasoning An analogy of the rights has been associated to the steps required in clinical reasoning. It is the right ability to collect the right cues, take the right action, for the right patient and at the right time and for the right reason. ‘Having the right cues indicate collecting the right most current information that have been handed over and may give the patient history, patient charts and results of investigation as conducted at various occasions’ ((Levette-Jones, et al 2010, pp 518). Patient assessment must be undertaken for proper diagnosis. While this is done, knowledge of physiology, pathos-physiology, and epidemiology must not be deleted in context in totality. The right cues also indicate having the right patient information from the patients signs and symptoms and relating with the normal and the abnormal standards. Clear lines must also be indicated for relevant from irrelevant details and highlighted on the most important information. This tries to establish the relationship between the patterns. Opinions or deductions are to be made by handling every information subjectively. According to the health records of Mr Smith, he seems to suffer from the recurrence of Arthritis, hypertension and Chronic obstruction of the pulmonary disease. COPD has common symptoms of heart failure and difficulty in breathing which seem to be a major sign of discomfort. Nurses are supposed to avoid prejudices and stereotypes as these assumptions may prevent the cues of the collection process. ‘This can be in the form of pre conceptions and generalisations such as all elderly people have ulcers’ (Woodhall, et al 2008, pp 314-317). Results generated influence the way the patients are managed and hospitalised. It is therefore imperative that nursing and physicians students be provided with valid examples during training so that they can be able to reflect on the opportunities that will enable them to question their assumption and prejudices. The right patient is one at risk and critically ill as a result of an adverse event. It is not yet established whether Mr Smith critical situation is a result of medication he is receiving or an advance of the hypertension and the COPD. Prioritising patients according to their need of immediate care is an important practice. The initial knowledge and association with patients enables nurses to grasp the clinical situation in order to sets the definitive physiological parameters which must be understood and that is only if the proper patient can be identified at the right time. Mr Smith final feeling of weakness, breathing problems despite being on a dose of oxygen at 24% does not yield any fruit, he seems to be uncomfortable and the situation is worsening on a daily basis with high rate of weight loss. Finally, complications and the final rescue should be put in place accordingly. ‘Early warning signs and modified warning scores apply the use of physiological parameters set as monitoring standards to check on patients who may become critically ill’ (Clarke & Aiken 2003,pp 69). Identified early and late cues of patients with adverse conditions such as cardiac arrest and even death need to be put under critical care. Other parameters that ought have been determined were pO2 in urine, blood glucose level if it is between 1-2.9mmol/L, Pulse rate if it false at 40-49 or 121-140 beats per minute for early symptoms and greater than 140 or less than 40 beats per minute, peripheral circulation and the systolic blood pressure. Unresponsiveness to verbal communication, hypoxia and difficulty in breathing due to alteration in blood gases are also very important signals for patients at risk. Continuous assessment of students in nursing on CR helps facilitate the development of their abilities in recognising of deteriorating patients and this ought to be practised on a routine basis to keep abreast with best practises as she had to have put all considerations to avoid negligence that led to worsening of the situation. The right time principle consist a complex and usually unpredictable episodes because it is usually a requirement to perform multiple clinical reasoning for every patient in their care. A study conducted on the intensive care units found out that the nurses were faced with a clinical judgement or decision after every thirty seconds. Time is the most valuable in reasoning. Identifying clinically risk patients in a time and administering interventions at the right time and procedure is very vital. Late recognition of critical patients and wrong interventions has been the key cause of failure rescue. ‘The right action is the behaviour following a radical judgement; it involves practical skills, intellectual skills and proper communication’ (Banning 2008, p 179). A plan basing on priority is usually the best protocol for easier interpretation. It includes other information on who takes the action, over what procedures and what policies are involved in the process and finally who should be notified in case of an emergency. Nursing id a profession that demands synthesis of facts and making inferences to make a definitive diagnosis. Identifying clinically risk patients and selecting a course of procedural intervention mechanism. ‘Right reasoning is an aspect of the right clinical reasoning according to the ethos, legal standards and professionalism’ (Hoffman, et al 2009, pp1337). It is the motive or the guiding rational. It also can be deduced that it may be right conclusion reached or the process and preferably both. Decision making demands accurate reasoning and this does not exist in isolation from the person executing the role. Experience and confidence of the decision maker determines the accuracy of CR. Personal attributes, orientation of roles, education and culture also play a supporting function. The right reasoning should not only be complete for the clinical reasoning, but also be just and compatible with the values and beliefs of the patient. Implementation Communication barrier among nurses and physicians leads to a breakdown in communication that causes adverse out comes. It is of this reason that nurses are taught to report in narrative form and hence providing many details as much as possible and this has its own demerits also because translation may became a problem. National patient safety has the Mandate to address such like issues to decrease the medical errors especially by particularly focussing on the communication between health care workers. A survey on the situation, background, assessment, recommendation (SBAR) to aid communication of nurses at the Magee Women’s Hospital started with the initial resistance. They sought clarification on whether they should recommend a medication prior to a physician’s examination. They were introduced to basic templates such as ‘R’ to indicate that something was wrong instead and assessment was required of saying it wholly. Other resistance were very minor and could not interfere seriously with the flow of the study. Consistency and good communication and the viability of associated reasoning eventually took over the argument. Similar application has been applied by the nurse taking care of Mr Smith. She directs the pharmacist conduct a pharmaceutical review of Mr Smith. Such like communication employ the working of SBAR as a tool for proper communication. It is however a late remedy considering that Mr smith has been on triple dosage as a result of complication from unidentified consequences. Discussion Communication and clinical reasoning in application to nursing practice, serves as an essential requirement for analysis and assimilation of health care evidences in line with the legal and ethical standings of our society. This is differentiated basing on efficacy and applicability. Mr Smith may have recovered early enough were it that early signs had been identified as a complex situation that may have required meta-cognition. Clinical reasoning can be attributed as the most significant element in the practice of nursing. This is not arguable due to the experience that can be demonstrated easily by the experienced nurses; the cognitive instincts that comes with professionalism. The nurse ought to have employed several judgemental criteria in handling Mr Smith. This comes in several modes of reasoning such as: problematic reasoning that identifies problems and their causative factors and finding solutions for them. It is a suitable method for identification of diagnosis and putting in practice the intervention plans. Theoretical reasoning exploits the deductive hypothetical situations that can either support or terminate the findings and conclusions. Operational reasoning takes an actual process for the identification of opposing views that may lead to determining solutions. Inductive reasoning on the other hand addresses from the specific to the general perspective when assimilated have purposive premises. This is only best in used orthopaedic care of bone fractures which has a direct correlation to stress and hence the obvious general conclusion of an altered state of health. Dialectic reasoning involves a holistic approach to finding solutions. The problems identified are analysed critically and combined to come up with the solutions. Merging of factors increases the power of offering solutions than handling independent analysis of factors. It capitalises on the strength, weaknesses, opportunities and possible threats in a patient’s problem. Clinical reasoning is a multi-disciplinary approach to problem solving, cognitive in nature that employs both informal and formal protocols to put together and analyse a patients information collected on cues or during information gathering while doing diagnosis. This has the final reflection on the patient’s management. Proper communication and reasoning are supported by the intuition and knowledge gained from professional experience. This will only require appropriate strategies to be employed. Intuition centres on production of specific knowledge forms that range from ethical, personal aesthetic and empirical to experience. The aspect of complexity of the task, education and the level of risk all define the intuition and the knowledge. Meta-cognition is the advanced level of the thinking process and has been defined as the thinking within the thinking. Think aloud strategy has already found application in accessing cognitive processes conducted in clinical reasoning. It mainly deals with collection of verbal data pertinent to the cognitive processes in problem handling. It has shown a lot of success in data collection associated with cognitive processing in the nursing and clinical scenarios. Prototypes developed to manage schema and cognitive thinking has been applied by experienced nurses. They reduce the cognition time and allow development of short cuts changing the trends from rule type reasoning to step by step analysis that does not have strain in cognition. Conclusions Success and failures has been a bench much for new strategies for preventing adverse endpoints. Mr Smith may have been an incidental subject due to ignorance by the nurses. However, clinical reasoning, problem solving or making judgements are pertinent issues in discussing issues with patients care. Standards is what helps sustain the check and balance of any system and individual nurses and clinicians have an obligation of accepting responsibility to devising appropriate environment that will enhance the nursing practice and all the medical physician’s in general. The major objective as we still contest about this fact is that patient rescue is the main objective of our professionalism. Further research should be allowed to be conducted on these issues to help discover new ways of making these professions better and more efficient now and the future so that similar occurrences just like what happened on Mr Smith do not arise again. References list Banning, M 2008, Clinical reasoning and its application to nursing: concepts and research studies, Nursing education in practice. Elsevier: Middle sex, United Kingdom, 8, (3). 177–183 Clarke, S & Aiken, L 2003, ‘Failure to rescue’, American Journal of Nursing 103 (1),pp 67-71. Hoffman, K. et al 2009, ‘A comparison of novice and expert nurses‟ cue collection during clinical decision-making: verbal protocol analysis’, International Journal of Nursing Studies, Volume 46 (10), pp 1335- 1344 Haig, KM, Sutton, S and Whittington, J 2006, ‘SBAR: a shared mental model for Improving communication between clinicians’, Journal on Quality and Patient Safety, Volume. 32,(3). Levette-Jones et al 2010, ‘The ‘’five rights‟ of clinical reasoning: An educational model to enhance nursing students‟ ability to identify and manage clinically “at risk‟ patients’, Nurse Education Today. Volume 30 (6), pp 515-520. Woodhall, L J, et al 2008, ‘Implementation of the SBAR Communication Technique in a Tertiary Centre’, Journal of Emergency Nursing August 2008, pp 314-317. Read More