3/2/2012
Transition from Knowledge to Clinical Reasoning
Marianne Spurgeon, MSN, RN
Director, Education Enrichment Services
Upon completion of this session, participant will be able to:
• Examine differences between foundational thinking, critical thinking, clinical judgment, and clinical reasoning
• Explore the importance of clinical reasoning in nursing practice.
• Discuss the use of virtual patients as a strategy to promote clinical reasoning.
Group Activity (5 minutes)
• What is knowledge, critical thinking, clinical reasoning, and clinical judgment? • How do they differ from one another?
• Why are they important to the practice of nursing?
• Why is it important to begin teaching these skills early in the program?
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Group Reports
• Knowledge
• Critical Thinking
• Clinical Reasoning
• Clinical Judgment
• Relationship to practice of nursing?
• Significance of teaching these skills early in the program?
Transition from Knowledge to Clinical
Reasoning/Clinical Judgment
Clinical Judgment
Clinical Reasoning
Critical Thinking
Knowledge
Knowledge
• Acquisition of facts and principles
• Recall – being able to retrieve previously learned knowledge; does not require an understanding of the information
– Example: The normal parameters for blood glucose is between 70‐105 mg/dL. • Comprehension ‐ being able to understand the knowledge retrieved and verbalize or use it in some manner. “Understanding” is another term used for comprehension. – Example: The nurse comprehends/understands/ that this reading is below the expected range and that the blood glucose is low.
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Critical Thinking
• The set of thinking skills used when analyzing client issues and problems
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Interpretation
Analysis
Evaluation
Inference
Explanation
• Facilitates the critical analysis of an issue
• Requires student/nurse to be able to:
– Think abstractly
– Generalize/transfer information
– Apply knowledge to client situations
(Peden‐McAlpine & Clark, 2002)
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RELATIONSHIP Between Knowledge and Critical Thinking
CLINICAL SITUATION: Upon assessment of the client who has a blood glucose of 56 mg/dL at 1600, the nurse finds that the client is also reporting hunger and difficulty concentrating . Vital signs reveal tachycardia.
Interpretation
Recognize, understand, and explain the
meaning of a situation The findings of a blood glucose of 56 mg/dL, hunger, difficulty concentrating, and tachycardia could indicate hypoglycemia.
Analysis
Examine the findings in relation to the situation and gather additional data as
needed to validate the findings. Upon review of the chart, the nurse finds that the client received 12 units of NPH Humulin insulin this morning at 0730. The client only ate 50% of her lunch and has not eaten anything since.
Evaluation
Assess the relevance, significance or applicability of the findings to the
situation.
The NPH Humulin insulin could be peaking and client’s intake has been inadequate for amount of insulin given.
Inference
Draw conclusions that are based on evidential data and are logical given the client situation.
Client is experiencing hypoglycemia
Explanation
Hypoglycemia is occurring because the NPH Humulin insulin is Justify the reasoning/conclusions drawn in peaking and client’s caloric load is inadequate for amount of insulin relation to the evidence and contextual on board.
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considerations.
Clinical Reasoning
• Mental process used when analyzing and evaluating all elements of a clinical situation and deciding on the best action to take
(Tanner, 2006)
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Identifying and collecting critical/relevant data
Processing information
Analyzing/interpreting data
Inferring possible conclusions
Planning and implementing interventions
Evaluating and reflecting on outcomes
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RELATIONSHIP Between Critical Thinking and Clinical Reasoning • Analysis is one of the most important cognitive skills of a critical thinker. • It involves:
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Scrutinizing all of the data surrounding a clinical situation
Determining the significance of each piece of data
Distinguishing relevant from irrelevant data.
Considering various interventions in relation to:
• Potential outcomes • Risk of positive and negative consequences
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Clinical Judgment
• Decision made regarding patient needs and action to be taken based on clinical reasoning.
RELATIONSHIP Between Clinical Reasoning and Clinical Judgment
• Clinical reasoning supports clinical judgments by:
– guiding the nurse through the process of assessing and compiling data, – selecting and discarding various bits of data based on their relevance to the client care situation
– making decisions regarding client care based on nursing knowledge 12
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Group Activity – 5 minutes
• Outline the clinical reasoning process required by a student in relation to the following example:
– Client’s IV is infiltrated but it is time to hang an IVPB antibiotic. What decisions must the student make to resolve this issue?
• What difference would you expect to see in how a beginning versus an advanced student handles the situation? Group Reports
• Decision making process related to infiltrated IV and scheduled antibiotic
• Difference in clinical reasoning skills between beginning and advanced students
Clinical Reasoning Requirements
• Active engagement • Deliberate practice
• Reflection on activities to improve performance 5
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Group Activity – 10 minutes
• Discuss how you can provide opportunities for students to practice clinical reasoning skills
• Identify what factors influence the quality of these opportunities?
Group Reports
• How you can provide opportunities for students to practice clinical reasoning skills
• What factors influence the quality of these opportunities?
Common Strategies to Promote Clinical Reasoning
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Written case studies
Role play
Simulation (low/high fidelity)
Simulated patients
Clinical experience
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Online Virtual Patients
• Interactive simulations with computer‐based patients in simulated clinical encounters
• Virtual patients are currently used in health care education by medicine, physical therapy and other disciplines
Lack in Clinical Reasoning Skills
• Failure to detect impending patient deterioration (del Bueno, 2005)
• Difficulty differentiating between acute problems and those needing immediate attention (O’Neil, 1994)
• Inappropriate judgments (Woods, 2002)
– Misidentify a situation
– Faulty logic due to the use of rote habitual action or convention; an unwarranted or faulty intervention
– Failure to recognize the implications of signs and symptoms identified in the assessment
Implications for Education
Students need to develop clinical reasoning skills
– Bring information to life
• Distinguish range of manifestations
• Recognizing changes in condition
• Evaluate response to treatment
– Ensure exposure to key topics/concepts
• Shortage of clinical sites
• Limited control of clinical experiences
– Provide opportunities to practice clinical reasoning skills
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Lead the Transition
Knowledge
Clinical Reasoning
References
Blumenthal D. (1994). Making medical errors into “medical treasurers. Journal of American Medical Association, 272, 1876‐1868.
Cook, D., Triola, M. (2009). Virtual patients: A critical literature review and proposed next steps. Medical Education. 43, 303‐311.
Del Bueno, D., (2005). A crisis in critical thinking. Nursing Education Perspectives, 5, 278‐
283.
Dreifuerst, K. (2009). The essentials of debriefing in Simulation learning: A concept analysis. Nursing Education Perspectives, 30(2), 109‐114. Ericsson, K. , Whyte, A., Ward, J., (2007). Expert performance in nursing: Reviewing research on expertise in nursing within the framework of the expert‐performance approach. Advances in Nursing Science, 30(1), 58‐71.
Fouad, Al., Burleson, J. (1997). Effectiveness of an endodontic diagnosis computer simulation program. Journal of Dental Education, 61(3), 289‐294.
Huhn, K., Deutsch, J., (2011). Development and assessment of a web‐based patient simulation program. Journal of Physical Therapy Education, 25(1), 5‐10.
References
Levett‐Jones, T., Hoffman, K., Dempsey, J., Yeun‐Sum Jeong, S., Noble, D., Norton, C. A., 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. Nursing Today, 30, 515‐220.
O’Neill, E., (1994). The influence of experience on community health nurses’ use of the similarity heuristic in diagnostic reasoning. Scholarly Inquiry for Nursing Practice, 8, 217‐261.
Tanner, C. (2006). Thinking like a nurse: A research‐based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204‐211.
Wahlgren C., Edelbring S., Fors, U., Hindbeck, H., Stahle, M. (2006). Evaluation of an interactive case simulation system in dermatology and venereology for medical students. 2011, from http://www.biomedcentral.com/1472‐6920/6/40.
Woods, A., Doan‐Johnson, S. (2002, October). Executive summary: Toward a taxonomy of nursing practice errors. Nursing Management, 45‐48.
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