Biomedical Decision Making: Probabilistic Clinical Reasoning

Author(s):  
Douglas K. Owens ◽  
Harold C. Sox
Author(s):  
Lois Stickley

Background: Clinical reasoning skills are embedded in all aspects of practice. There is a lack of consensus and standards for curriculum design and teaching methods of clinical reasoning in entry-level education of health professionals. Purpose: The purpose was to describe a process of designing one comprehensive, planned sequence of four courses to create significant learning experiences for clinical reasoning for Doctor of Physical Therapy students. Method: Fink’s design process was used to develop four clinical decision-making courses to ensure a close alignment of learning goals, feedback and assessment, and learning activities to engage students in practicing components of clinical reasoning. Student outcomes were measured by self-efficacy ratings for clinical reasoning in a practical exam for first-year students and by ratings of performance by clinical instructors for third-year students. Results: 41 first-year students ranked their confidence in making clinical decisions both before and after a midterm practical. A paired t-test found a significant difference (.05t40 = -6.66, ρ=0.00) in the mean ratings of students from the pre-practical assessment to the post-practical assessment about confidence in making clinical decisions. Third-year students received ratings that met or exceeded expectations on five audited skills from the Physical Therapist manual for the Assessment of Clinical Skills (PT MACS), both at midterm and at the final assessment. No significant differences between midterm and final ratings on any of the selected skills were found using a Chi-Square Test of Independence (α=.05). Conclusion: The four-course sequence was designed using four themes: patient-centered care, models of practice, and evidence-based practice, and ethics/legal issues. This paper offers specific details about how one method of teaching clinical reasoning meets the current trends in education and health care for accountability and meaningful outcomes. Students gained practical knowledge and skills in the components of clinical reasoning and decision-making by participating in active and engaging significant learning experiences.


Author(s):  
Deborah Roberts

This chapter introduces the underlying principles of decision making. You will be encouraged to consider decision making as a student in university together with decision making as a student nurse (see Chapter 1 ). In 2010, following a review of pre-registration nursing education, the professional body for nursing in the United Kingdom, the Nursing and Midwifery Council (NMC), published new Standards for Pre-Registration Nursing Education , including competencies that all students must achieve to qualify as a registered nurse. These competencies have to be met in four broad areas known as ‘domains’. 1. Professional values 2. Communication and interpersonal skills 3. Nursing practice and decision making 4. Leadership, management, and team working You will find reference to these domains throughout the book, and there will be an opportunity to learn how the competencies in each of these that relate to decision making can be linked to your clinical and university-based learning. There are a number of terms that can be found in the literature that are often used interchangeably; you may see terms such as ‘decision making’, ‘problem solving’, ‘clinical reasoning’ or ‘clinical judgement’, and others used when writers are discussing how and why nurses respond to clinical situations in a particular way (see Chapter 1 for more detail). For example, Levett-Jones et al. (2010: 515) provide a helpful definition of clinical reasoning as ‘the process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process’. They also emphasize that a nurse’s ability to develop these clinical reasoning skills depends on what they term as ‘five rights’—that is, the nurse’s ability ‘to collect the right cues and to take the right action for the right patient at the right time and for the right reason’. In the context of ensuring that any patient receives the best possible care, these ‘five rights’ are very appropriate, and indeed if one were to fail to pick up on the right cues and to take the appropriate actions in many clinical situations, the outcome may have serious repercussions for the nurse and the patient.


2020 ◽  
Author(s):  
Kristin Jeppestøl ◽  
Marit Kirkevold ◽  
Line Kildal Bragstad

Abstract Background: Acute functional decline is a common clinical syndrome in geriatric health care that is typically characterised by nonspecific symptoms and presents with a mix of physical, psychological, social and functional manifestations.Early warning score (EWS) systems are widely implemented in nursing homes and home care to detect clinical deterioration. The effects of EWS systems have been thoroughly evaluated in hospital care settings, but few studies have evaluated these systems in community health care.The purpose of this study is to describe the experiences of registered nurses (RNs) and general practitioners (GPs) when using the Modified Early Warning Score (MEWS) to support clinical reasoning and decision-making with geriatric home care patients who suffer from acute functional decline.Method: A qualitative methodology was used with a descriptive exploratory design. Data were collected from seven focus group interviews. GPs and RNs were purposively sampled from large, medium and small municipalities in Norway. Data were analysed using an inductive content analysis method.Results: MEWS was used as an additional decision-making tool with elderly home care patients when acute functional decline was detected. RNs and GPs emphasised that MEWS supported the clinical reasoning and decision-making process. Additionally, those applying MEWS required comprehensive reasoning skills and specific knowledge of the patients. RNs identified the need for contextual adjustments to the use of MEWS in home care settings. Implementing MEWS has improved the collaboration and clinical practice of RNs and GPs. The adherence to MEWS follow-up recommendations was adjusted to the home care setting, accounting for potentially limited medical availability.Conclusion: MEWS supported RNs and GPs in conducting comprehensive clinical assessments and reasoning when acute functional decline was detected. Interdisciplinary communication and collaboration appeared to be strengthened, and GPs’ work was streamlined. Several limitations were identified with the use of MEWS reference values with geriatric patients, which could lead to ambiguity and misjudgements. MEWS trigger recommendations were experienced as inappropriate in the home care context. This study identifies the need for a modified, evidence-based EWS adjusted for geriatric patients in home care.


Author(s):  
Molly Harrod ◽  
Sanjay Saint ◽  
Robert W. Stock

Through clinical reasoning, seasoned physicians correctly diagnose patients’ problems and develop appropriate treatments. It has two main components. The first is the ability to mentally stockpile and integrate information gathered in the process of treating many patients and reading research, allowing physicians to recognize patterns of data and sometimes make automatic diagnoses. The process is intuitive and nonanalytical. The second major facet of clinical reasoning is analytical. Physicians painstakingly examine and weigh all evidence, including patients’ clinical history and physical examination, to develop hypotheses and management plans. Attendings viewed the use of “why” questions as teaching opportunities. Questions served multiple purposes, including guiding the learners through their thinking processes, building on knowledge through hypothetical questions, and using the Socratic method to foster critical thinking. Instilling the ability to think critically about one’s own decision-making process was the attendings’ ultimate goal for their learners.


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