Code of ethics in health education

Clinical pathway

 

 

                               

 Definition of clinical pathway

Criteria of clinical pathway

Factors affect clinical reasoning

process of clinical reasoning cycle

Importance of clinical reasoning

References

Introduction

  The terms ‘clinical reasoning’ ‘clinical decision making’, ‘medical problem solving’ and ‘diagnostic reasoning’ are often used interchangeably. All these terms refer to the same idea, which was described by Barrows as ‘The cognitive process that is necessary to evaluate and manage a patient’s medical problem (Barrows & Tamblyn 1980)’

 Clinical Reasoning is the process by which a therapist interacts with a patient, collecting information, generating and testing hypotheses, and determining optimal diagnosis and treatment based on the information obtained.

Volume7, Issue2

Special Issue: Evidence Based Medicine

May 2001

Pages 109-117

  

 

  Definitions of clinical pathway

 A clinical pathways They are multidisciplinary plans of "best" clinical practice, which identifies the appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes for a homogenous patient group. (Quality Improvement and Enhancement Program, Clinical Pathways Board: 2002).

  Clinical pathway refers to the thought process (clinical reasoning) that allows healthcare providers to arrive at a conclusion (clinical decision-making) based on objective and subjective information about a patient

Laura M. Cascella, MA 2018

  Clinical reasoning, also known as clinical judgment, is the process by which clinicians collect signs, process information, understand the patient’s medical situation or problem, plan and implement appropriate medical interventions, evaluate outcomes, and learn from this entire process.

By Eric Brown Posted on h 7, 2018

  ‘Unsworth^’ stated, clinical reasoning is how I think and make decisions when I'm planning to be with a client, when I'm with a client, and afterwards when I reflect on therapy.

Clinical reasoning is:

How I think about what the client is telling me and what I observe.

What I pay attention to and ignore.

What I respond to immediately or note for future reference.

The way I try to understand my client as a human being.

How I draw on my knowledge of previous clients, their difficulties and successful and unsuccessful solutions.

The way I draw on my theoretical knowledge and apply this in practice

Carolyn A. Unsworth, in Stroke Rehabilitation (Fourth Edition), 2016

  

Criteria of clinical pathway

 A component of clinical reasoning involves the individual achieving a balance between evidence based practice and practice that is based on his/her own experience.

Evidence-Based Guidelines

Evidence based practice is the process of applying the best available research results when making decisions about health care. Health care professionals who perform evidence-based practice use research evidence along with clinical expertise and patient preferences in providing care.

Practice Guidelines

Guidelines provide clinicians and patients the recommendations for screening, diagnostic and therapeutic actions that are known or believed to favorably affect the health outcomes of patients. Guidelines are not meant to replace the clinical judgement of the individual provider or establish a standard of care. They are meant to be flexible and are only considered recommendations.

Standards of Care

Where Guidelines are meant to be flexible, standards are a rigid set of criteria, meant to be followed under any circumstances. These are practices that are medically necessary for the management of a clinical condition.

 Factors affect clinical pathway

 Several studies highlight factors which influence the use of clinical reasoning including: communication and relationships; educational level; knowledge and ability to use critical thinking; familiarity with the environment and the context of care, experience and exposure to a variety of situations as well as professionalism.

JBI Database of Systematic Reviews and Implementation Reports: December 2017 –

 

    Effective use of the clinical reasoning cycle is directly linked to:–

The ability to collect the right cues; and take the right action, for the right patient

At the right time; for the right reason

Levett-Jones (2010)

 

Process of the Clinical Reasoning Cycle

Consider the patient

Collect cues/information

Process information

Identify problems/issues

Establish goals

Take action

Evaluate outcomes

Reflect on process and new learning

By: Paul Ross 27/11/2017 

 

 

 

 

The phases of the clinical reasoning process with examples

 

Process	Description	Example
Consider the patient situation	Describe or list facts, context, objects or people	This 60 year old patient is in ICU because he had an abdominal aortic aneurysm (AAA) surgery yesterday
Collect cues/ information	Review current information (e.g. handover reports, patient history, patient charts, results of investigations and nursing/medical assessments previously undertaken)	He has a history of hypertension and he takes beta blockers His BP was 140/80 an hour ago
	Gather new information (e.g. undertake patient assessment)	I’ve checked his BP and it is now 110/60, Temp 384 . Epidural running @ 10ml/hr
	Recall knowledge (e.g. physiology, pathophysiology, pharmacology, epidemiology, therapeutics, culture, context of care, ethics, law etc)	BP is related to fluid status. Epidurals can drop the BP because they cause vasodilation. In ICU we have standing orders for epidural management.
Process information	Interpret: analyses data to come to an understanding of signs or symptoms. Compare normal Vs abnormal.	His BP is low, especially for a person who is normally hypertensive
	Discriminate: distinguish relevant from irrelevant information; recognize inconsistencies, narrow down the information to what is most important and recognize gaps in cues collected.	His temp is up a bit but I‟m not too worried about it – I‟m more concerned about his BP and pulse. I’d better check his urine output and his O2 sat.
	Relate: discover new relationships or patterns; cluster cues together to identify relationships between them.	His hypotension, tachycardia and oliguria could be signs of impending shock. His BP went down after we increased the epidural.
	Infer: make deductions or form opinions that follow logically by interpreting subjective and objective cues; consider alternatives and consequence	His BP could be low because of blood loss during surgery or because of the epidural
	Match current situation to past situations or current patient to past patients (usually an expert thought process)	AAAs often have hypotension post op
	Predict an outcome (usually an expert thought process)	If I don’t give him more fluids he could go into shock
Identify problem / issue	Synthesize facts and inferences to make a definitive diagnosis of the patient’s problem.	He is hypovolemic and the epidural has worsened the BP by causing vasodilation.
Establish goals	Describe what you want to happen, a desired outcome, a time frame.	I want to improve his hemodynamic status – get his BP up and urine output back to normal over the next hour.
Take action	Select a course of action between different alternatives available	I will ring the doctor to get an order to increase his IV rate and to give aramine if needed
Evaluate	Evaluate the effectiveness of outcomes and actions. Ask: “has the situation improved now?”	His BP is up for now but we will need to keep an eye on it as he may still need aramine a bit later. His urine output is averaging > 30mL/hr now
Reflect on process and 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 …

Adapted from Hoffman (2007); Alfaro-LeFevre (2009); Andersen (1991)

 

  

Why is clinical reasoning important?

  Clinical reasoning is best described as the thin line between a patient’s death or deteriorating health status and recovery. Nurses or clinicians with poor clinical reasoning place a patient’s health condition at risk of deterioration and in a lot of cases, death.

The benefits of having sound clinical reasoning include Identification and logical interpretation of symptoms, Planning of care to alleviate, or prevent complications or relapses; making timely diagnoses, making prompt life-saving treatment plans, avoiding unnecessary investigations which reduces cost for the patient, and ultimately improving the patient’s health condition.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Clinical Reasoning: An Important Aspect of Clinical Skills

By Eric Brown

Posted on March 7, 2018

4 Clinical today

min read

 

 

SYSTEMATIC REVIEW PROTOCOLS

Characteristics and processes of clinical reasoning in nurses and factors related to its use

a scoping review protocol

Griffits, Susan1; Hines, Sonia2; Moloney, Clint1; Ralph, Nicholas1Author Information

JBI Database of Systematic Reviews and Implementation Reports: December 2017 - Volume 15 - Issue 12 - p 2832-2836

doi: 10.11124/JBISRIR-2016-003273

 

»Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S. Y.-S., Noble, D.,Norton, C. A., . . . Hickey, N. (2010). The 'five rights' of clinical reasoning:An educational model to enhance nursing students' ability to identify andmanage clinically 'at risk' patients.

Nurse Education Today, 30(6), 517- 519.

 

Carolyn A. Unsworth, in Stroke Rehabilitation (Fourth Edition), 2016