clinical reasoning cycle essay

8 Stages Of The Clinical Reasoning Cycle

Last updated on August 19th, 2023

In this article, we will be exploring the clinical reasoning process and its importance in healthcare.

The clinical reasoning cycle, developed by Tracy-Levett Jones, breaks down this process into eight phases that healthcare professionals can follow to make informed decisions for their patients.

These phases include considering facts, collecting information, processing gathered information, identifying the problem, establishing goals, taking action, evaluating the effectiveness of the action, and reflecting on the experience.

By following this cycle, healthcare professionals can enhance their problem-solving and decision-making skills, leading to better patient care.

Related: Clinical Reasoning In Nursing (Explained W/ Example)

8 Stages of the Clinical Reasoning Cycle

The eight stages of the Clinical Reasoning Cycle are the following.

• considering the patient’s situation,
• collecting cues/information,
• processing information,
• identifying problems/issues,
• establishing goals,
• taking action,
• evaluating outcomes, and
• reflecting on the process.

These eight phases guide healthcare professionals in providing optimal care to patients.

Each stage is interconnected and builds upon the previous one, allowing for a comprehensive understanding of the patient’s needs and effective decision-making.

1. Consider the patient’s situation

The first phase of the Clinical Reasoning Cycle involves considering the facts presented by the patient or situation. This is where healthcare professionals receive the initial information and medical status of the patient.

For example , they may be given details about a newborn admitted to the Neonatal Intensive Care Unit (NICU) due to neonatal jaundice.

By carefully considering these facts, healthcare professionals can start to develop an understanding of the patient’s condition and determine the appropriate course of action.

2. Collect cues/ information

In the second phase, healthcare professionals gather additional information to gain a comprehensive understanding of the patient’s medical history, complaints, treatment plan, and current vital signs.

They may also review the results of any investigations or tests conducted. This information is then analyzed using the healthcare professional’s knowledge of physiology, pharmacology, pathology, culture, and ethics to establish cues and draw conclusions.

The collection of information is a crucial step in the clinical reasoning process, as it helps healthcare professionals to identify any underlying issues or potential challenges.

3. Process information

The third phase involves the processing of the information gathered in the previous step.

It is here that healthcare professionals critically analyze the data on the patient’s current health status in relation to pathophysiological and pharmacological patterns.

They determine which details are relevant and consider potential outcomes for the decisions they may make.

This phase requires healthcare professionals to use their expertise and judgment to identify the key issues that need to be addressed.

4. Identify problems/issues

Based on the processed information, healthcare professionals can identify any problems or issues that the patient may be facing.

This involves recognizing signs and symptoms, understanding the underlying causes, and determining the potential impact on the patient’s health.

5. Establish goals

Once the problems or issues are identified, healthcare professionals can establish goals for the patient.

These goals are aimed at addressing or resolving the identified problems and improving the patient’s health outcomes.

Goals should be specific, measurable, achievable, relevant, and time-bound (SMART).

6. Take action

After establishing goals, healthcare professionals take appropriate actions to address the identified problems and work towards achieving the established goals.

This may involve implementing treatment plans, providing interventions, administering medications, or coordinating care with other healthcare professionals.

7. Evaluate outcomes

The seventh phase of the Clinical Reasoning Cycle is evaluation. In this phase, healthcare professionals assess the effectiveness of the actions they have taken.

They evaluate whether the treatment plan has been successful in achieving the desired outcomes or if adjustments need to be made.

This phase allows healthcare professionals to reflect on their decisions and make informed judgments about the next steps in the patient’s care.

8. Reflect on the process and new learning

The final phase of the clinical reasoning cycle is reflection. Healthcare professionals reflect on the entire process, including their decision-making, actions taken, and the outcomes achieved.

This reflection allows for continuous learning and improvement, as healthcare professionals gain insights from their experiences and apply them to future situations.

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Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.

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ten Cate O, Custers EJFM, Durning SJ, editors. Principles and Practice of Case-based Clinical Reasoning Education: A Method for Preclinical Students [Internet]. Cham (CH): Springer; 2018. doi: 10.1007/978-3-319-64828-6_10

Principles and Practice of Case-based Clinical Reasoning Education: A Method for Preclinical Students [Internet].

Chapter 10 a model study guide for case-based clinical reasoning.

Maria van Loon , Sjoukje van den Broek , and Olle ten Cate .

Affiliations

Published online: November 7, 2017.

• All bold-faced text is to be used for paragraph headings and may be used as the actual format.
• Annotations and explanations are given between square brackets [..] or in footnotes.
• The text is derived from the study guide used at UMC Utrecht. At some points adaptations should be made to meet local needs.

Student Instructions and Background Materials for the CBCR Group Meetings

• Authors: [name, role, affiliation, office, telephone for contact]
• Year: [year of validity of the guide]

Table of Contents

Justification.

• Coordination
• Credit points
• 1. Introduction
• 2. The Objectives of the CBCR Course
• 3. What Is Clinical Reasoning and Decision-Making?
• 4. The CBCR Sessions
• 5.1 CBCR Session Participation Points
• 5.2 The CBCR Test
• 5.3 Rules for Test Participation and Passing
• 5.4 Rules for the Exam Retake
• 5.5 Rules for Repeaters

[Names of case writers and developers of the course.]

Coordinating team

[Names and affiliations of course director and team members; contact information of the coordination team.]

Credit Points

Having successfully completed the CBCR course in Year […] provides […] credits.

• Introduction

[Gives a short general introduction on the CBCR course.]

Case-based clinical reasoning, a series of meetings on clinical decision-making, constitutes an important part of the curriculum. This education not only serves as a training in the methods of clinical decision-making but also provides an opportunity to apply previously acquired knowledge to clinical problems.

Students will learn clinical reasoning by using written clinical situations. In CBCR the complaint of the patient is the key starting point for reasoning. From this complaint, a case is worked through toward a diagnosis and sometimes proceeds to a management plan in a structured way. CBCR basically asks you to think in a way that is used later in clinical practice. The systematic unraveling of a clinical problem is essential in the practice of the profession of a doctor. In addition, working in groups does not only encourage the learning process but also stimulates to argue the diagnostic process step by step.

Between the CBCR classes there is time reserved for independent study. Preparatory self-directed learning improves the efficiency of the group meetings significantly and also distributes your study load more evenly.

The Objectives of the CBCR Course

[Describes the learning goals/objectives of the course.]

CBCR focuses on learning to solve clinical problems. By doing this, knowledge from pathophysiology, epidemiology, and clinical decision-making is integrated.

Evaluation of collected data and making clear how they relate to a complaint/medical problem

Using of biomedical, epidemiological, and clinical knowledge in patient problems

Making a focused differential diagnosis and evaluating all relevant hypotheses

Giving a general direction which therapy and/or guidance is suitable

In addition, the student has acquired the skill to deal with new patient problems as presented at the doctor’s office aligned with CBCR cases in the course.

Next, there is a focus on developing leadership skills. After successfully completing the CBCR course, the student is able to lead a meeting on clinical reasoning.

• What Is Clinical Reasoning and Decision-Making?

[As students are mostly not really aware what clinical reasoning and clinical decision-making is, an explanation is necessary, illustrated by an example.]

Without giving a conclusive definition of clinical decision-making, it can be said that this form of education is about the rational considerations that underpin every step in the clinical encounter that starts at the moment when a patient presents at the doctor’s office, until the moment that an end is reached in this contact.

The nature of this process is usually that of solving a medical question or problem. The considerations that guide that process are an essential part of the group discussions. The quality of the arguments, considerations, and decisions made is just as important as the solutions to be found. Many arguments include both pathophysiological and non-pathophysiological arguments. Pathophysiological arguments concern the construction and functioning of the body up to a molecular level and the disturbance of them. Non-pathophysiological arguments usually relate to epidemiological, but sometimes to ethical or social considerations. Eliminating a pathophysiological argued statement because a particular phenomenon in a certain group of people rarely occurs is an epidemiological founded argument. Also the decision not to carry out a specific diagnostic test because the costs and burden on the patient are in no proportion to the information that the doctor will receive is a non-pathophysiological argument. Clinical decision-making is schematically displayed below (Boxes 10.1 and 10.2 ):

Box 10.1 A Roadmap to Clinical Decision-Making

Identify what the question(s) is/(are) of the patient. As long as the patient’s request for help is not clarified , you will need to ask further questions, until it is completely clear what questions, wishes, and expectations the patient has.

After the request for help is clarified, formulate possible diagnoses before you start with history taking.

Estimate the order of likelihood of hypotheses within the differential diagnosis.

Argue every diagnosis with pathophysiological and non-pathophysiological arguments.

What next history question should you ask? What does an answer tell you?

What next part of the physical examination would you perform? Why?

What diagnostic tests would you now like to order?

• Argue every question and every diagnostic test. If you want to collect multiple data, make a priority list of what needs to be asked/done first.

Evaluate the data collected through history and additional research.

Repeat 3–6 until you have a most likely diagnosis and you cannot gain more certainty about the diagnosis. Then proceed to prognosis and therapy.

Box 10.2 Example Case Using the Roadmap for Clinical Decision-Making

The request for help might be: “What is the cause of my fatigue?”

The first assumption in this case is obvious: Is the heavy menstruation the cause of the anemia and, therefore, the fatigue with exertion? What possible

causes of anemia are there?

Disorder in the production

Loss of blood

Hemolytic anemia

An iron-deficiency anemia based on a heavy menstruation is most likely based on the following arguments:

Epidemiological argument: Iron-deficiency anemia is by far the most common.

Pathophysiological argument: A heavy menstruation can indeed lead to anemia.

Deepening the history with special history questions is not very burdensome. Yet efficiency is desired. So it is wise to ask first for her menstruation cycle. Asking for blood with defecation (in case of suspicion on a bowel tumor) comes later in the hierarchy. Of course, you should also ask about other causes of fatigue with exertion, for example, complaints matching asthma – you know that anemia does not always give complaints of fatigue.

There is also a hierarchy in the physical examination. A gynecological examination gives us probably more information than a rectal examination (a fibroid in the uterus is sometimes felt better than a tumor in the rectum).

Many different diagnostic tests can be done to determine the cause of the anemia, such as MCV, hematocrit, and ferritin. However, it is important for each test to be aware of the (cost) effectiveness. MCV and hematocrit are cheap, not very stressful, and deliver a significant diagnostic result. However, a colonoscopy is expensive and stressful, and the chance that this patient has a carcinoma is small.

• The CBCR Sessions

[This is a practical section and describes how the sessions take place and what is expected of the students].

During the CBCR sessions you will work through written clinical cases in a group of students. Every session, three students take the role of peer teacher and lead the session. A consultant is present to act as supervisor.

Introduction Session

In an introduction session, the students and their consultant get acquainted with each other. The consultant explains the purposes of CBCR course and gives the instructions for the sessions. Rules and regulations are set. The first three peer teachers are chosen, and they receive the peer teacher version of the first case.

Preparation and Self-Study

A distinction is made between the preparation of the students and the peer teachers. The peer teachers (three students rotating in the group) prepare the case thoroughly in advance so that they are able to lead the meeting. All other students prepare the meeting at home with the student version of the case. This preparation is necessary to ascertain a high-level discussion . All cases can be prepared using the prescribed literature given in the cases.

CBCR Sessions

Each session takes 2 h, 1 and during these sessions, patient cases will be discussed, increasing in difficulty over the course.

The aim of each session is to elaborate a clinical problem. At first a hypothesis or differential diagnosis is formulated after a patient problem has been introduced. This is elaborated by asking relevant questions on the problem and to test the first hypotheses. Too much or unfocused questioning means that the process is not well finished. The process of formulating and testing hypotheses is repeated one or more times after additional information is provided by means of “handouts” that include information of the history, the physical examination, imaging tests, and/or specified laboratory research. Before the sessions, only the peer teachers have handout information, which they will distribute during the class. Afterward, the handouts will be available for all students.

Tasks of Peer Teachers

Peer teacher roles for the first and subsequent sessions are assigned at the introduction session. By turn, at each session three students perform the role of peer teacher; every student fulfills this role at least twice 2 during the course. Peer teachers lead CBCR meetings. They have prepared the case using the peer teacher version of the case, which they have received from the consultant at the end of the previous session. This version of the case provides additional hints for the peer teachers. As a result, they are able to work through the complete case before the session, lead the discussion in the meeting, give comments on the arguments of other group members, and provide well-funded answers. During the session one of the peer teachers gives a mini-lecture to provide the students with additional information about a certain diagnosis, test, or therapy. The instructions for this are given in the peer teacher’s version.

• Introduction : Introduction of the patient and formulation of the patient problem.
• Answering : Answering of the first questions by every student or in little groups (2–3 students).
• Inventory of the answers : Especially the arguments are important.
• Reflection on the responses : Reflection on the responses by the peer teachers and explanation of what they think that the proper responses are (a mini-lecture can be useful).
• Brief summary : At the end of the case, one of the students gives a brief summary of the patient and his/her complaint.
• Evaluation : The student participation is evaluated and assessed by the consultant, material for the next meeting is distributed, and the case or the meeting is discussed and evaluated.

The value of CBCR consists of the ability of students to formulate new hypotheses based on new information received. Therefore, it is very important that the students do not know in advance how the case will proceed and do not know answers on the history or diagnostics. As peer teachers you are kindly but firmly requested not to give any information concerning the case to students who haven’t had this meeting yet.

• Make sure that the students have answered the questions the best they can. Only then provide them with comments and additions.
• Avoid the group to become passive. Involve every student in the discussion. Even the students who haven’t prepared properly can try to answer questions.
• Bring literature to the sessions. Any unforeseen questions can be answered, and a solution can be found during the session. The consultant should not be the primary source of information, but can be asked for feedback in case the group cannot continue.
• The peer teachers determine the course of the meeting. The role of the consultant can be limited if the peer teachers are well prepared.
• The peer teachers can use a whiteboard, flip over, or PowerPoint to make tables or to use it for their mini-lecture.
• Peer teachers play an important role in the evaluation of the cases. Any comments they have should be handed to the consultant.
• CBCR trains peer teachers in leadership skills. Three roles can be distinguished.

Takes the lead

Divides turns to get everyone involved (in addition actively involve silent students, e.g., let the neighbor of an answering student argue the answer given)

Ensures time management

Identifies key issues after the discussion

Provides a conclusion at the end of a question

Writes down keywords on the board and fills in the table

Is critical; is not easily satisfied with the answers given by the students

Asks thoroughly: what does a student mean with an answer?

Seeks answers to questions that remain unresolved on the spot, to be able to answer them before the end of the meeting.

It is important that the tasks are alternated during the meeting, since the consultant will assess peer teachers on their overall performance.

The Mini-Lecture

• Use as little text as possible on the slides
• Use a clear structure
• Make sure you have an evident message and conclusion
• Be cautious with details

Check if your message comes trough

Ask questions

Mind your voice and presentation

Be aware of the level of preparation of the students

N.B. The mini-lecture is not meant as a recitation for the peer teachers or merely an exposure of their content knowledge, but is meant to teach the students. Mini-lectures should not take more than about 5 min.

PowerPoint and Whiteboard

Experience has shown that the use of PowerPoint during the CBCR session can undermine the clinical thinking process. Therefore, its use should be limited to showing handout texts and to support a mini-lecture. It is advised to use the blackboard or whiteboard as much as possible in the interactive discussions on hypotheses and disease symptoms. Building a clear table (with diagnostic hypotheses and diagnostic findings on the two axes) helps with structuring a reflective thinking process.

Tasks of Regular Students

All students are expected to be prepared and show active participation in the meetings.

Tasks of the Consultant

The main task of the consultant is to encourage the students to have a meaningful discussion about the clinical problem. He or she acts as a supervisor. As for the provision of content knowledge, the teacher is a true consultant, reacting to student requests for information if needed. In addition, the consultant’s task is to assess the active participation of all students. The consultant gives feedback, especially to the peer teachers.

At the end of the session, as an administrative task, the consultant hands out the peer teacher versions to the peer teachers for the next session.

[Gives information on assessment of group meeting and final assessment of the course and general rules on missing sessions]

The course requirements include both active participation at sessions as students and as peer teachers and passing the CBCR test. Participation makes up 12 % and the test score 88 % of the final mark. 3

Active participation at all meetings is expected. Missed sessions may be replaced in another group. Attending at another group is advisable if this other group and the consultant agree, but this is not rewarded with points. In case of three or more sessions missed, students need to contact the coordinator and may gain an exception through the study counselor if they have a sound reason. 4

CBCR Session Participation Points

[Gives information on how students are assessed during group meetings, see for more explanation Chap. 7 . Make a distinction between points for students and points for peer teacher. Describe the criteria for receiving points/scores clearly.]

Active Participation During the Group Meetings: Students

The assessment of the participation occurs at the end of each meeting. The consultant indicates which students have actively participated, considering the following criteria 5 :

Unsatisfactory participation in the discussion. Each student should participate in the discussion. A student who remains silent out of embarrassment or modesty is stimulated by the peer teachers or consultant, but must participate. Silent presence is not enough.

Unsatisfactory preparation. From the active participation should show that there is a thorough preparation. Only with background knowledge a student can make a meaningful contribution . It is not enough if the student wants to participate but doesn’t give substantive contribution . The latter doesn’t mean to create an exam atmosphere, but it is important to properly prepare for each meeting.

Peer Teachers Roles

Peer teachers are expected to show a more extensive preparation than the students. The peer teachers must have a substantive performance at the meeting, which is especially reflected in the quality of justifying reports of the thinking steps in the clinical process. They must demonstrate pathophysiological background knowledge and understanding of the clinical process.

0 for poor preparation, no good leadership of the session

1 for moderate preparation, moderate leadership of the session

2 for good preparation, good leadership of the session

Each student must fulfill the peer teacher role twice. It is possible to earn a maximum of 1 bonus point by fulfilling the role of peer teacher for a third time to compensate for illness or absence at another meeting. There are never more than three peer teachers per meeting. The group as a whole is responsible for ensuring that there are at least two students functioning as a peer teacher at every meeting.

We aim to provide good quality education by the consultants for the lessons. It is however possible that guidance or marking by the consultants leads to a dispute with a student. For any comments or disputes, we ask you kindly to contact the coordinator of the course [email address].

The CBCR Test

[In this paragraph students should be explained when the test will take place and what they can expect for the test. Examples of possible questions can be given here.]

The CBCR test is composed of questions that begin with a brief case description in which the age, sex, and the complaint with which the patients presents himself at the doctor are made clear. After this some additional information may be given and several questions follow.

The students are asked to choose the correct answer out of a table. The possible answers are displayed in a table, broken down by category: “diagnosis,” “history features,” “physical examination,” “diagnostic test options,” and “management.” Sometimes there is asked for only one answer, sometimes for more.

A mock exam will be distributed a month before the test.

[Here example of test questions can be included. See for an example of the Utrecht CBCR test Chap. 7 , Table 7.1].

Rules for Test Participation and Passing

[In this section the terms and conditions to participate in the test should be described. If students must have fulfilled certain conditions as minimal points for participation or minimal presence, this should be clarified here. Any regulations about possible compensation for missed classes can be described. Rules for passing the CBCR course need to be described.]

Rules for the Exam Retake

[Any rules and regulations for the exam retake should be clarified here.]

Rules for Repeaters

[Any rules and regulations for the repeaters should be clarified here.]

Duration of the sessions depends on local schedules. We advise a minimum duration of 1.45 and a maximum of 2.30 h.

Depending on the number of sessions and number of students per group. This is an example of the situation at the University Medical Center Utrecht.

This is an example of the University Medical Center Utrecht, where participation during sessions makes 12 % and the test score 88 % of the final mark. In nine sessions, with a peer teacher assignment twice, 11 points can be earned (7*1 point plus 2*2 points). Access to the final written test requires at least 5 points for active participation. Points from 6 on (until 11) are counted toward the overall final score, while each of those points counts twice, yielding 12 points (6*2). This is 12 % of the overall final score.

Rules mentioned in this paragraph are used at the University Medical Center Utrecht, however, can be adapted to align with the local situation.

Criteria and scores mentioned in this paragraph are used at the University Medical Center Utrecht, however, can be adapted to align with the local situation.

Open Access  This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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• Cite this Page van Loon M, van den Broek S, ten Cate O. A Model Study Guide for Case-Based Clinical Reasoning. 2017 Nov 7. In: ten Cate O, Custers EJFM, Durning SJ, editors. Principles and Practice of Case-based Clinical Reasoning Education: A Method for Preclinical Students [Internet]. Cham (CH): Springer; 2018. Chapter 10. doi: 10.1007/978-3-319-64828-6_10
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In this Page

• Student Instructions and Background Materials for the CBCR Group Meetings
• The Objectives of the CBCR Course

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Advanced practice: critical thinking and clinical reasoning

Sadie Diamond-Fox

Senior Lecturer in Advanced Critical Care Practice, Northumbria University, Advanced Critical Care Practitioner, Newcastle upon Tyne Hospitals NHS Foundation Trust, and Co-Lead, Advanced Critical/Clinical Care Practitioners Academic Network (ACCPAN)

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Advanced Critical Care Practitioner, South Tees Hospitals NHS Foundation Trust

Clinical reasoning is a multi-faceted and complex construct, the understanding of which has emerged from multiple fields outside of healthcare literature, primarily the psychological and behavioural sciences. The application of clinical reasoning is central to the advanced non-medical practitioner (ANMP) role, as complex patient caseloads with undifferentiated and undiagnosed diseases are now a regular feature in healthcare practice. This article explores some of the key concepts and terminology that have evolved over the last four decades and have led to our modern day understanding of this topic. It also considers how clinical reasoning is vital for improving evidence-based diagnosis and subsequent effective care planning. A comprehensive guide to applying diagnostic reasoning on a body systems basis will be explored later in this series.

The Multi-professional Framework for Advanced Clinical Practice highlights clinical reasoning as one of the core clinical capabilities for advanced clinical practice in England ( Health Education England (HEE), 2017 ). This is also identified in other specialist core capability frameworks and training syllabuses for advanced clinical practitioner (ACP) roles ( Faculty of Intensive Care Medicine, 2018 ; Royal College of Emergency Medicine, 2019 ; HEE, 2020 ; HEE et al, 2020 ).

Rencic et al (2020) defined clinical reasoning as ‘a complex ability, requiring both declarative and procedural knowledge, such as physical examination and communication skills’. A plethora of literature exists surrounding this topic, with a recent systematic review identifying 625 papers, spanning 47 years, across the health professions ( Young et al, 2020 ). A diverse range of terms are used to refer to clinical reasoning within the healthcare literature ( Table 1 ), which can make defining their influence on their use within the clinical practice and educational arenas somewhat challenging.

The concept of clinical reasoning has changed dramatically over the past four decades. What was once thought to be a process-dependent task is now considered to present a more dynamic state of practice, which is affected by ‘complex, non-linear interactions between the clinician, patient, and the environment’ ( Rencic et al, 2020 ).

Cognitive and meta-cognitive processes

As detailed in the table, multiple themes surrounding the cognitive and meta-cognitive processes that underpin clinical reasoning have been identified. Central to these processes is the practice of critical thinking. Much like the definition of clinical reasoning, there is also diversity with regard to definitions and conceptualisation of critical thinking in the healthcare setting. Facione (2020) described critical thinking as ‘purposeful reflective judgement’ that consists of six discrete cognitive skills: analysis, inference, interpretation, explanation, synthesis and self–regulation. Ross et al (2016) identified that critical thinking positively correlates with academic success, professionalism, clinical decision-making, wider reasoning and problem-solving capabilities. Jacob et al (2017) also identified that patient outcomes and safety are directly linked to critical thinking skills.

Harasym et al (2008) listed nine discrete cognitive steps that may be applied to the process of critical thinking, which integrates both cognitive and meta-cognitive processes:

• Gather relevant information
• Formulate clearly defined questions and problems
• Evaluate relevant information
• Utilise and interpret abstract ideas effectively
• Infer well-reasoned conclusions and solutions
• Pilot outcomes against relevant criteria and standards
• Use alternative thought processes if needed
• Consider all assumptions, implications, and practical consequences
• Communicate effectively with others to solve complex problems.

There are a number of widely used strategies to develop critical thinking and evidence-based diagnosis. These include simulated problem-based learning platforms, high-fidelity simulation scenarios, case-based discussion forums, reflective journals as part of continuing professional development (CPD) portfolios and journal clubs.

Dual process theory and cognitive bias in diagnostic reasoning

A lack of understanding of the interrelationship between critical thinking and clinical reasoning can result in cognitive bias, which can in turn lead to diagnostic errors ( Hayes et al, 2017 ). Embedded within our understanding of how diagnostic errors occur is dual process theory—system 1 and system 2 thinking. The characteristics of these are described in Table 2 . Although much of the literature in this area regards dual process theory as a valid representation of clinical reasoning, the exact causes of diagnostic errors remain unclear and require further research ( Norman et al, 2017 ). The most effective way in which to teach critical thinking skills in healthcare education also remains unclear; however, Hayes et al (2017) proposed five strategies, based on well-known educational theory and principles, that they have found to be effective for teaching and learning critical thinking within the ‘high-octane’ and ‘high-stakes’ environment of the intensive care unit ( Table 3 ). This is arguably a setting that does not always present an ideal environment for learning given its fast pace and constant sensory stimulation. However, it may be argued that if a model has proven to be effective in this setting, it could be extrapolated to other busy clinical environments and may even provide a useful aide memoire for self-assessment and reflective practices.

Integrating the clinical reasoning process into the clinical consultation

Linn et al (2012) described the clinical consultation as ‘the practical embodiment of the clinical reasoning process by which data are gathered, considered, challenged and integrated to form a diagnosis that can lead to appropriate management’. The application of the previously mentioned psychological and behavioural science theories is intertwined throughout the clinical consultation via the following discrete processes:

• The clinical history generates an initial hypothesis regarding diagnosis, and said hypothesis is then tested through skilled and specific questioning
• The clinician formulates a primary diagnosis and differential diagnoses in order of likelihood
• Physical examination is carried out, aimed at gathering further data necessary to confirm or refute the hypotheses
• A selection of appropriate investigations, using an evidence-based approach, may be ordered to gather additional data
• The clinician (in partnership with the patient) then implements a targeted and rationalised management plan, based on best-available clinical evidence.

Linn et al (2012) also provided a very useful framework of how the above methods can be applied when teaching consultation with a focus on clinical reasoning (see Table 4 ). This framework may also prove useful to those new to the process of undertaking the clinical consultation process.

Evidence-based diagnosis and diagnostic accuracy

The principles of clinical reasoning are embedded within the practices of formulating an evidence-based diagnosis (EBD). According to Kohn (2014) EBD quantifies the probability of the presence of a disease through the use of diagnostic tests. He described three pertinent questions to consider in this respect:

• ‘How likely is the patient to have a particular disease?’
• ‘How good is this test for the disease in question?’
• ‘Is the test worth performing to guide treatment?’

EBD gives a statistical discriminatory weighting to update the probability of a disease to either support or refute the working and differential diagnoses, which can then determine the appropriate course of further diagnostic testing and treatments.

Diagnostic accuracy refers to how positive or negative findings change the probability of the presence of disease. In order to understand diagnostic accuracy, we must begin to understand the underlying principles and related statistical calculations concerning sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratios.

The construction of a two-by-two square (2 x 2) table ( Figure 1 ) allows the calculation of several statistical weightings for pertinent points of the history-taking exercise, a finding/sign on physical examination, or a test result. From this construct we can then determine the aforementioned statistical calculations as follows ( McGee, 2018 ):

• Sensitivity , the proportion of patients with the diagnosis who have the physical sign or a positive test result = A ÷ (A + C)
• Specificity , the proportion of patients without the diagnosis who lack the physical sign or have a negative test result = D ÷ (B + D)
• Positive predictive value , the proportion of patients with disease who have a physical sign divided by the proportion of patients without disease who also have the same sign = A ÷ (A + B)
• Negative predictive value , proportion of patients with disease lacking a physical sign divided by the proportion of patients without disease also lacking the sign = D ÷ (C + D)
• Likelihood ratio , a finding/sign/test results sensitivity divided by the false-positive rate. A test of no value has an LR of 1. Therefore the test would have no impact upon the patient's odds of disease
• Positive likelihood ratio = proportion of patients with disease who have a positive finding/sign/test, divided by proportion of patients without disease who have a positive finding/sign/test OR (A ÷ N1) ÷ (B÷ N2), or sensitivity ÷ (1 – specificity) The more positive an LR (the further above 1), the more the finding/sign/test result raises a patient's probability of disease. Thresholds of ≥ 4 are often considered to be significant when focusing a clinician's interest on the most pertinent positive findings, clinical signs or tests
• Negative likelihood ratio = proportion of patients with disease who have a negative finding/sign/test result, divided by the proportion of patients without disease who have a positive finding/sign/test OR (C ÷ N1) ÷ (D÷N1) or (1 – sensitivity) ÷ specificity The more negative an LR (the closer to 0), the more the finding/sign/test result lowers a patient's probability of disease. Thresholds <0.4 are often considered to be significant when focusing clinician's interest on the most pertinent negative findings, clinical signs or tests.

There are various online statistical calculators that can aid in the above calculations, such as the BMJ Best Practice statistical calculators, which may used as a guide (https://bestpractice.bmj.com/info/toolkit/ebm-toolbox/statistics-calculators/).

Clinical scoring systems

Evidence-based literature supports the practice of determining clinical pretest probability of certain diseases prior to proceeding with a diagnostic test. There are numerous validated pretest clinical scoring systems and clinical prediction tools that can be used in this context and accessed via various online platforms such as MDCalc (https://www.mdcalc.com/#all). Such clinical prediction tools include:

• 4Ts score for heparin-induced thrombocytopenia
• ABCD² score for transient ischaemic attack (TIA)
• CHADS₂ score for atrial fibrillation stroke risk
• Aortic Dissection Detection Risk Score (ADD-RS).

Conclusions

Critical thinking and clinical reasoning are fundamental skills of the advanced non-medical practitioner (ANMP) role. They are complex processes and require an array of underpinning knowledge of not only the clinical sciences, but also psychological and behavioural science theories. There are multiple constructs to guide these processes, not all of which will be suitable for the vast array of specialist areas in which ANMPs practice. There are multiple opportunities throughout the clinical consultation process in which ANMPs can employ the principles of critical thinking and clinical reasoning in order to improve patient outcomes. There are also multiple online toolkits that may be used to guide the ANMP in this complex process.

• Much like consultation and clinical assessment, the process of the application of clinical reasoning was once seen as solely the duty of a doctor, however the advanced non-medical practitioner (ANMP) role crosses those traditional boundaries
• Critical thinking and clinical reasoning are fundamental skills of the ANMP role
• The processes underlying clinical reasoning are complex and require an array of underpinning knowledge of not only the clinical sciences, but also psychological and behavioural science theories
• Through the use of the principles underlying critical thinking and clinical reasoning, there is potential to make a significant contribution to diagnostic accuracy, treatment options and overall patient outcomes

CPD reflective questions

• What assessment instruments exist for the measurement of cognitive bias?
• Think of an example of when cognitive bias may have impacted on your own clinical reasoning and decision making
• What resources exist to aid you in developing into the ‘advanced critical thinker’?
• What resources exist to aid you in understanding the statistical terminology surrounding evidence-based diagnosis?

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Clinical reasoning: Learning to think like a nurse

Updated 22 May 2023

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Category Profession ,  Psychology ,  Health

Topic Nurse ,  Interventions ,  Patient

Nurses must employ approaches that attempt to increase the quality of health interventions and patient safety in order to improve patient outcomes. Because the majority of their work in health care environments includes making clinical judgments, it is critical that they have an organized approach of reasoning to assist them make effective choices. Nurses, according to Dougherty, Thompson, and Kudenchuk (2013), play a critical role in developing interventions to improve a patient's response to illness, ability to adapt to illness, and ability to live with a life-changing condition. For these reasons, they must be able to make appropriate decisions that result in excellent patient outcomes. The Clinical Reasoning Cycle (Levett-Jones, 2012) is one of the best ways for nurses to decide the intervention a patient’s needs. This essay aims to apply the clinical reasoning cycle to a clinical problem showing how a nurse made use of the process to improve a patient’s condition. It will also provide some recommendations that student and registered nurses can use to better their practice.

Patient Problem

The patient was a 35-year-old man suffering from tuberculosis. He arrived at the hospital complaining of a continuous cough, malaise and breathlessness. His partner stated that he had also lost his appetite for some time leading to weight loss. They had been on holiday in India about four weeks prior to the hospital visit.

Stage One: Patient Consideration

According to Levett-Jones (2013), the clinical reasoning cycle should start by taking into consideration all aspects related to a patient’s condition and note any intervention that the patient has received. As a result, the case under consideration in this essay begins with that approach. The patient was a 35-year-old man who presented a history of coughing and breathlessness after a visit to India. Moreover, he complained of a continuous feeling of fatigue. He had lost weight, and apart from a persistent cough, he showed no other physical problems.

Stage Two: Collecting Information

In this stage, the nurse gathers all the information that a patient can provide using different methods, such as clinical testing and questioning the patient. The primary reason for this assessments is to prevent adverse events and detect trends in the deterioration of a patient’s condition (Coyne & Needham, 2012). The patient had indicated the presence of a persistent cough raising suspicion of a TB infection. After interrogating the patient, the nurse gathered some cues concerning the patient’s condition. He never experienced night sweats. Clinical wisdom collected by the nurse has shown that tuberculosis can lead to night sweats, particularly among young adults (Mold, Holtzclaw & McCarthy, 2012). The nurse needed to remove this possibility hence the interrogation. Nevertheless, the additional information provided by the patient’s spouse, for instance the loss of appetite and weight, made the nurse pursue the potential of a tuberculosis infection further. This situation raised the need for more testing because he had mentioned that it was the first time he was seeking treatment.

The next step was a physical examination of the patient that involved drawing some blood. During the physical assessment, the student nurse noted a crepitation over his lung apices. The crepitation in the lungs was in the form of a rattling noise during inhalation. Literature reveals that crepitations are a common symptom among TB patients. An observation of 60 TB patients in one study revealed that 83.3% had crepitations (Vipin & Solanke, 2012). This information reaffirmed the nurse’s suspicions that the patient had tuberculosis despite the blood test showing normal levels of white blood cells and haemoglobin. The result led the student nurse to consult the lead nurse who recommended a sputum test, a chest X-ray and a Mantoux test.

After the chest X-ray, the nurses working with a nurse manager identified some shadowing in the upper and middle lobe although there was no enlargement of the hilar. The hilum on both sides showed a branching vascular look with the blood vessels leading from them tapering and diminishing. According to Sarkar et al. (2013), normal hilar appear this way. The X-ray showed a darkened upper and middle lobes a problem that has been associated with TB patients (Cadena et al., 2016).

The sputum analysis detected the presence of bacteria in the patient’s mucus. The analysis detected some Mycobacterium and acid-fast bacilli. Evidence-based practice demands that nurses gather all relevant information concerning a patient’s condition to enable them make informed decisions that enhance patients’ outcomes (Ellis, 2016). A Mantoux test was the final confirmatory test a. It gave positive results, and the patient was diagnosed with pulmonary tuberculosis. The nurse collected all the information together and passed it on to the lead nurse for confirmation before presenting it to a doctor for further analysis and for the patient to begin treatment.

Stage Three: Process Information

Levett-Jones (2012) gives the next stage in the clinical reasoning cycle as processing and analysis of information. Several techniques can be used in this stage to present a clearer understanding of a patient’s health condition: interpretation, discrimination, relation, inference and predicting. In the interpretation phase the nurse examined the information to understand the signs and symptoms that the patient presented. The patient complained of a constant feeling of fatigue for a young person. The feeling of being tired indicates an abnormality in the patient’s health.

The student nurse then moved on to discriminate the information given by the patient and his spouse. When questioned by the nurse, the couple said that he had not experienced night sweats. Although night sweats are a common occurrence among TB patients, some patients may not experience them as seen in the Vipin & Solanke (2012) study. The student nurse noted this but discriminated the information as it was not sufficient to rule out the presence of TB.

Relation of the information collected was another step in the clinical reasoning cycle. It involved making connections between the symptoms the patient displayed and symptoms associated with a particular illness, in this instance tuberculosis. The patient complained of three signs that normally present themselves in TB patients: persistent coughing, loss of appetite and a feeling of general tiredness. The three symptoms were a pointer to the possibility of TB. Furthermore, the crepitation in the lung also reinforced the suspicion.

After interpreting, discriminating and relating the information collected from the patient, the next step was to make some inferences from it. Sarkar et al. (2013) asserted that the hilum on both sides of the lung should have a branching vascular look and the blood vessels leading from them should narrow and diminish as they spread. The patient’s lungs in this case appeared normal. Nevertheless, the lungs had darkened lobes which have been associated to TB infection. This information was enough to make the nurse student recommend a sputum test to prove TB and a chest X-ray. The nursing student also recommended a Mantoux test that confirmed the student nurse initial thought.

Stage Four: Identify the Problem

The fourth stage of the clinical reasoning cycle involves the nurse finding facts concerning a patient’s condition (Levett-Jones, 2012). The sputum test, chest X-ray and Mantoux tests confirmed the nursing student’s feeling that the patient had TB. The TB was responsible for the overwhelming feeling of fatigue, loss of appetite and persistent coughing. It was likely that the patient has contracted the illness while on tour in India.

Stage 5: Create Goals

In this phase of the cycle, nurses should establish goals whose realization will lead to positive outcomes for a patient’s health. Working together with a registered nurse, the student nurse established the primary aim as treating the TB infection that would reinstate the patient’s health.

Stage Six: Action

This stage involves nurses taking action and creating a plan that will make it possible to realize the aim identified earlier. The registered nurse together with the nursing student spoke to the nurse in charge of the unit to determine the next course of action. After giving the information to the head nurse, the nurse called a doctor who examined the patient and confirmed the symptoms the nurse student had observed. The doctor also examined the sputum test results, chest X-ray and the Mantoux test before recommending treatment. Following the examination of the evidence and conclusion that the nursing student was dealing with a TB patient, the doctor recommended the antibiotics rifampicin and isoniazid for six months. The medications would be accompanied by pyrazinamide in the first two months of treatment.

Stage Seven: Evaluation

The seventh stage of the clinical reasoning cycle presented an opportunity for the nursing student to evaluate the process and deduct some recommendations on how to improve the application of the process in clinical practice. This phase was to involve an examination of the entire process from the moment the nursing student met the couple to their exit from the hospital after receiving the medication and instructions on how to use it.

Stage Eight: Reflect on the Process and Recommendations

The final stage of the clinical reasoning cycle allows nurses to reflect on their clinical decisions as well as make any suggestions on how to improve the process (Levett-Jones, 2012). Reflecting on the process that led to the TB diagnosis and recommended treatment, the nursing student has made several observations that could lead to improvements in clinical practice. First, the nursing student observed that the absence of an enlarged hilar is not an indication of the absence of TB. As mentioned in the case, the patient showed no signs of a larger hilar despite the TB diagnosis. Nurses should pay attention to this issue as overlooking it could lead to a misdiagnosis that leads to poor patient outcomes.

Second, the nurse student recognized the need for greater testing when confronted with divergent symptoms. Although the nursing student’s initial suspicion was that the patient had TB, some of the symptoms that the patient presented contrasted this belief, such as the normal hilar in the patient’s chest X-ray. This problem shows that there is a risk that a nurse may misdiagnose a patient. Phillips (2015) states that misdiagnosis and failure to treat TB properly can lead to transmissions. The clinical reasoning cycle above provides proof that nurses should take all the possible actions needed to eliminate the presence of an illness. Such actions could help in improving the outcomes for a patient and protecting other people from infections.

Poor patient outcomes following a treatment can be attributed to incorrect misdiagnosis, failure to implement the right treatment and inappropriate management of complications that a patient presents (Sommers & Fannin, 2014). Therefore, nurses should take a holistic approach to the diagnosis and treatment of patients’ problems. Nurses must learn to look for all the information they can gather from their patients, collect their own data and communicate the information with other nurses, particularly those who have served in the profession for several years. A second opinion on a problem can help to gain better understanding of the symptoms patients present in their health problems, particularly where a patient does not exhibit the signs that are usually associated with a specific ailment.

In conclusion, the clinical reasoning cycle is an important tool for nurses to enhance their practice. It makes it possible for nurses to gain deeper understanding of a patient’s problem as well as the possible actions that they can take to improve patient outcomes. Through it, nurses can also learn to exercise greater caution in their work to prevent misdiagnosis and ensure they give patients the most effective treatment for their problems. Furthermore, the cycle provides nurses with a means to evaluate their actions in the diagnosis and treatment process which can help them to prevent such mistakes in future. The clinical reasoning cycle is a tool that should be recommended for practice among student and registered nurses for its efficacy in disease treatment.

Cadena, M. A., Klein, C. E., White, A. G., Tomko, A. J., Chedrick, C. L., Reed, S. D., Via, E. L., Lin, L. L. & Flynn, L. J. (2016). Very low doses of mycobacterium tuberculosis yield diverse host outcomes in common marmosets (Callithrix jacchus). Comparative Medicine, 66 (5), 412-419.

Coyne, E. & Needham, J. (2012), Undergraduate nursing students placement in specialty clinical areas: Understanding the concerns of the student and registered nurse. Contemporary Nurse, 42 (1), 97-104.

Dougherty, M. C., Thompson, E. A. & Kudenchuk, J. P. (2013). Development and testing of an intervention to improve outcomes for partners following receipt of an implantable cardioverter defibrillator. ANS Adverse in Nursing Science, 35 (4), 359-377.

Ellis, P. (2016). Evidence-based practice in nursing. London, Sage Publications.

Levett-Jones, T. (2013). Clinical reasoning: Learning to think like a nurse. Melbourne, Pearson Australia Group.

Mold, J. W., Holtzclaw, J. B., McCarthy, L. (2012). Night sweats: A systematic review of the literature. Journal of the American Board of Family Medicine, 25 (6), 878-893.

Phillips, J. A. (2015). Global tuberculosis. Workplace Health & Safety, 63 (10), 476-476.

Sarkar, S., Jash, D., Maji, A. & Patra, A. (2013). Approach to unequal hilum on chest X-ray. The Journal of Association of Chest Physicians, 1 (2), 32-37.

Sommers, M. S. & Fannin, E. (2014). Diseases and disorders: A nursing therapeutics manual. Davis, CA: F.A. Davis.

Vipin, P. & Solanke, V. P. (2012). Prevalence of tuberculosis cases in Sree Mookambika Institute of Medical Science. International Journal of Contemporary Medicine, 4 (1), 7-10.

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Clinical Reasoning Cycle Essay Examples

There are number of clinical reasoning and decision making models used in nursing practice, however this essay will discuss evidence based-practice and the ethical/legal models. Each model will be discussed in turn, first providing an overview, explaining its use and aim in healthcare. Then an example of method use will be discussed. The relevant factors that may help or hinder the use of the method will be then be considered. The final section will explain and illustrate how decision making is different across all fields of nursing and how this may impact on the patient experience. Finally the essay will consider how the two models and methods are used in practice to deliver patients centred care and how future practice it may be enhanced from learning gain through researching this essay. Clinical Reasoning Cycle Essay Examples

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According to Wickens et al (2004), CR and DM are refer to times when nurses and other health care professionals use their cognitive processes and critical thinking , previous experience and protocols to understand a patient’s problem. She added that the nurses then plan and implement interventions, evaluate the outcomes and reflect and learn from the process.

Evidence based practice (EBP) is a systematic approach to clinical decision making, within the health care sector. It combines scientific evidence, clinical experiences as well as patient preferences and values about care and treatment (Melnyk and Fineout-Overholt, 2005). This is used in nursing practice to provide guidelines for nurses. For example, the National Institute for Clinical Excellence (NICE) (2008), guidance which provides an overview of how conclusions can be drawn in an attempt to identify the most appropriate action. Rubin (2007) however, summarises two disadvantages of EBP model by saying that it is too mechanistic, ignores the characteristic of both clients and practitioners and is hard to implement due lack of time and may be outdated when printed. Killen and Barnfather,(2005) disagree with Rubin by stating EBP does consider patients’ preferences and practitioners’ influences in DM. A study carried out by them suggested that using EBP improves patients’ outcomes when compared with those using non EBP nursing care. Additionally, they added the EBP has positioned the nurse to be a significant influence on health care decisions and improving the quality of care.

Allen & Rixson (2008), systematic research was an example of EBP, to review of the impact of Integrate Care Pathways (ICPs) on providing an ‘integrated service’ for patients. The review focused on the care of adult patients who had suffered a stroke and included acute care, rehabilitation and long-term support in hospital and community settings. ICPs were the intervention of interest and ‘service integration’ was the outcome. They critically appraised seven papers, representing five studies. In conclusion the ICPs can be effective, in ensuring that patients receive relevant clinical assessments and interventions in a timely manner and in improving the documentation of rehabilitation goals. Evans (2003), proposes that nurses should use evidence derived from research to make a decision such as expert opinion according to quality criteria, randomised control trials and patient experience. Also it is important for nurses to understand why certain things are done not simply how to do it, for example giving drugs using via syringe driver, nurses should ask “why, when and how” which would help them to understand the importance of the process of action. Clinical Reasoning Cycle Essay Examples

A example of a method for EBP is a pain assessment tool for which guidance was developed by The British Pain Society has worked with the British Geriatrics Society and the Royal College of Physicians (2007), to review the current evidence guidance to help nurses and all practitioners to use pain assessment tools to assess for the presence of pain. The guidance helps nurses to be aware of the pain in patients, enquires about the pain by using a range of descriptive such as is it sore, hurting or aching will enable the nurse to reach decision. Furthermore, it helps nurse to locate the pain by asking the patient to point the area themselves to indentify the pain intensity and to identify the cause of the pain and how to treat and to re-evaluate the outcomes.

Pain assessment tool helps nurses to determine the cause and provide best pain management and treatment for the patient. In order for the nurse to assess pain comprehensively, the nurse needs to address the type of pain, detailed history and assessment of the pain intensity. This will helps the nurse to select a pain assessment tools based on the patient’s age, physical, emotional, cognitive status and preference (Kaasalainen and Crook, 2003). Verbal Rating Scale (VRS) is one of the pain assessment tool use to assess pain in patient. It aim is to mange the pain intensity by asking the patient to match pain to a descriptor words and number. The reasoning of using the VRS is what McCaffery 1968, defines pain should be what the patient says it is because a nurse can not measure a patient pain intensity unless the patient said so (Baillie, 2005, p 485). According to Krohn (2002), the nurse uses the VRS scale to ask the patients to describe their pain whether they have on pain, mild pain, moderate pain, sever or worst pain. Once the pain intensity is assessed according to Wells et al (2008), the nurse has to make a decision on which analgesic management and intervention to use in order to achieve optimal comfort and function with minimal side effect from analgesic therapy.

The World Health Organisation (WHO) (1986), suggest that nurses decision should be based on the analgesic administration ladder. Where simple analgesic such as paracetemol should be used for mild pain, weak opioids for moderate pain if not contraindication to renal dysfunction (Ballantye et 2002). A sever or worst pain should be review and a strong opioids analgesic such as morphine should be administer to improve the comfort of the patient. The nurse should monitor and be caution about the safety of the patient because first time analgesia patient will be susceptible to adverse effects such sedation and respiratory depression (National Patient Safety Agency 2008). Clinical Reasoning Cycle Essay Examples

Time management is a factor that hinder the use of pain assessment tool. A randomly studies carried out by Manias et al (2005). The study finds out that interruption such as answering the telephone, participating in doctors’ rounds effect pain assessment and possible delay the management of the pain. They added that due to this interruption patient are unable to request pain relief for the fear of being regarded as a nuisance and it have impact on their emotional, physiological and physical function aspect of their lives. Knowledge of pharmacology and analgesic also enhance to decrease anxiety, improve the mood and promote comfort to the patient.

Although using pain assessment tools in adult who speak English and understand the pain score is very effectively are able to give consent about their treatment, but in elderly adult with cognitive impairment will be confuse and not be to able give a reliable measurements of pain intensity, which is likely to result in inappropriate intervention. According to Weiner and Herr (2002), assess pain in patient with impaired communication such as learning disability and mental health patient represent the most significant challenges in pain management and nurses have difficulty knowing when those patient are in pain and when they are experience pain relief. They added that nurse have to depend on their facilitators to describe the pain in which the nurse have to query the reliability during decision. Pain assessment tools used in children is complex for example babies who are unable to communicate, decision and consent has relays on their parent. So during decision making about interventions, the nurse have to use ethical principles of beneficence and non-maleficence to select best pain assessment to provide pain comfort for all the patient (Nursing and Midwifery Council (NMC) (2004).

According to Wood (2001), nurses in the health care sectors encounter multiple challenges when providing quality care to diverse patient population. This creates ethical dilemmas resulting form the combination of increasing of patients acuity and limited of resources. She added that professional code of practice as a method will enable nurses to make an ethical decision to provide a patient centred care. in order to avoid inconsistency.

Ethical decision making as explain by Ian et al (2006), is when a nurse carefully rational the available evidence by asking a question such as what is the context of the dilemma or the data. identifying the ethical components such as what is the underlying problem or issues. Consider the relevant moral principles such as what alternatives exist and the purpose of each alternative, the consequences of our actions such as what are the social and legal constraints. However they also added, understanding of ethics and law is therefore important in order to guide DM and helps nurse to uphold patients right and protect vulnerable form harm. Also acting accordance with legal and professional code of practice can helps protect accountable nurses from legal action. Clinical Reasoning Cycle Essay Examples

The NMC code (2008), recommend that all nurses have the responsibility to work in partnership with patients, their families, carers and organisation. The professional code of practice as a method will provides guidance on how nurse would resolve clinical dilemma during DM. Mooi (2011), stated that, the professional code of practice is an evidence research ethics principles derived from moral philosophy to capture the essential virtues, rights and duties and outcomes , in order for nurses to achieve a patient centred care. He also added that the code of practice consists of four principles which are autonomy which respecting patients’ rights, non-malefiecence not to harm patients, beneficence, promoting the well-being of the patients and justice, treating patient fairly. Ian et al (2006), states that the professional code aids nurses in DM, first of all the nurse assess the background condition affecting the patient life in question and the immediate cause that demand decision, what are the alternative options available and what are likely outcomes will be. The nurses have to consider the relevant rules and moral principles relating to one’s personal and professional duties.

For example a 45 year old woman make an informed refusal about life-preserving treatment against the advice of her clinical team and her family opinion that resuscitation would be a benefit and ought to be undertaken. Although a nurse wish is to achieve good of life preserving and avoid harm of death, Beauchamp and Childress (2001), suggested that in this case, when making a decision the nurse should analysed the 45 year old woman rights, assess her capability of decision and if competent her rights of autonomy should be respect and honoured according to the professional code of ethics practices. According to Snelling (2010), non-maleficence requires that the nurse and other health care professional should not harm the patient. They suggest that during DM, the nurse should research and examine past experience of the success or failure of alternative courses of action when dealing with similar problems. This will helps the nurse to recognise treatment that would be considered beneficial for this patient. Also the nurse need to promote the well-being of the patient. Beneficence helps the nurse to assess the patient circumstances throughout the process of changing moral demand in the patient health situation (Ref). It also helps the nurse to decide where the best interest of the patient lies, and if the nurse overrides that patient wishes for example giving surgical treatment, this is done not out of spite but in the belief of acting in beneficence way. During DM, the nurse applied justice, although the patient refuse life-preserving treatment, she should be treating fairly by assuring that an appropriate standard of care is maintained. In order not to violate the ethical rights of the patient. Clinical Reasoning Cycle Essay Examples

Baron (2000), state that lack of knowledge leads nurses to make justified by biased reasons. Since knowledge requires reasoning and calculating the problem from the outside. In a course of resolving dilemma will leads the nurse to imagined sequences of event, the nurse will then make inadequate decision for unknown unexpected reasons. Furthermore he stated that this will prone the nurse to be inadequate when selected ethical decision and this will affect the outcomes and also the standard care delivered or cause harm to the patient. He also suggest that lack of self confidence influence DM in non-rational ways because since nurses are motivated to minimise conflict Capacity can be reduce in many ways such as illness, mental health, learning disability and childhood .

Ethical DM across nursing fields has issues relating to the ability to understand information and consent given. It also raising issues relating to their capacity. Under the Mental Capacity Act (2005), the patient must be presumed to have capacity unless there is evidence otherwise. Autonomy is the sense of having a capacity of making a decision, learning disability or a child may lack the capacity to make decision and to give consent about their medical treatment. This may delay treatment, legally the medical team include the nurse should decide in the best interest of the patient’s as suggested by Cornock, (2002), and their relatives views should not dismissed. Mental health patient’s ability to understand and give consent also depend on their capacity of competent. This is difficult where there is some doubt whether the patient can or not make a decision. Sometimes an adult patient may refuse treatment () of clinical The nurses should assess if the patient has sufficient capacity to give consent then it should be honoured in. Clinical Reasoning Cycle Essay Examples

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Clinical Reasoning Cycle: Laparoscopic Cholecystectomy Essay

The patient situation, collection of cue/information, process information, pain relief following laparoscopy, safety, legal and clinical issues, reference list.

We have Cicek Olcay, a 53-year-old Turkish woman who checked in the Day Procedure Unit (DPU) at 0700 hrs. Olcay has checked in complaining of acute right upper quadrant pain which had lasted for two months. She was attended to by the senior surgical registrar and surgeon last week.

After carrying out the initial examination, Olcay was booked for elective surgery for cholecystitis and cholelithiasis. Following admission, the DPU confirmed that the consent form was signed by Olcay and she was put on general anesthesia and the abdomen initial tests of F.B.E., U&E, and L.F.T were done.

The pre-operative checklist was also carried out with fasting status being confirmed that the patient had fasted from midnight and had not taken any medication in the morning. Olcay was transported to the Operating room at 0800 hours where the D.P.U nurses handed over the report to the O.R room nurse and Olcay was admitted. Her surgery was conducted as planned and the removal of her gallbladder was successful and showed no complications.

Olcay was transferred to the post-anesthetic recovery room – P.A.R.U where the P.A.R.U nurse continued monitoring her after every five minutes until she was ready to be discharged having met the discharge criteria. The notes attached indicate that she recovered well from the procedure and after 30 minutes she is ready to be discharged back to the D.P.U.

Olcay failed to be transferred back to the DPU after she complained of shoulder pain and the transfer had to be canceled. The pain was rated 6 on VAS and she was held in PARU following consultations with an anesthetist to undergo further pain relief therapy. After 15 minutes, she was reviewed and the surgeon together with the anesthetist recommend and request that she remains in the hospital overnight for further pain relief. Olcay was transferred to the ward after her admission was organized and approved.

Review current information

Cicek Olcay has a history of smoking and had previously undergone lower uterine segment Caesarean section – LUSCS . She also has a history of mental health. Other information includes; her temperature was 36 degrees, her respiration rate of 18, her blood pressure of 126/72, her pulse rate was 69, and a BSL of 6.4.

Collecting new Cues

Five cues need to be addressed at this point (Hussain, 2001, p. 245). The blood pressure has to be measured and rated based on the percentage related to the preoperative value. The ambulation progress is also important to assess whether the patient can walk without vertigo or is suffering from serious vertigo when walking.

The patient has to be assessed for nausea and vomiting (Hussain, 2001, p. 245). The scale is 2 for minor vomiting symptoms, 1 for moderate, and 0 for severe. Pain has to be assessed based on the Verbal Analog Scale VAS where a rate of 1-2 is minor, 3-4 moderate and more than 4 is severe pain. Finally, bleeding has to be checked and the wound checked to be satisfactory.

Recall knowledge

Shoulder tip pain is a common symptom observed in patients following laparoscopic cholecystectomy (Bennett et al., 2000, p. 193). It was initially recognized by gynecologists in their practice and this incidence varies though it remains common as about one-third of the patients who undergo laparoscopic surgeries experience it. This type of pain is particularly prevalent in cholecystectomy (Yeh et al, 2008, p. 484). The pain lasts for a few hours or up to 3 days but it can be easily relieved by the use of simple analgesics like codeine (Young & O’Connell, 2001, p. 3) and acetaminophen.

Patients also suffer nausea in 24 hours following surgery but this is easily controllable by the use of medication that is why Olcay did not experience nausea but recovered well. The cause of the nausea is often the procedure or the medication used in the process. Patients experience great discomfort in their right upper abdomen and shoulder areas (Yeh et al, 2008, p. 484).

The pain in the right shoulder is a ‘referred pain; as it is attributed to the effects of carbon dioxide that is normally administered in the abdomen when the surgery is taking place (Kandil & El Hefnawy, 2010, 679).

The gas has an effect on the diaphragm and the diaphragm has a nerve supply that also serves the shoulder and this causes the shoulder to sense pain when the diaphragm is irritated (Vezakis et al., 1999, P. 891; Young & O’Connell, 2001, p. 3). The symptoms fade away in a day or two and once discharged, the patient is required to rest for some weeks and gradually resume her normal daily routines and later return to normal activities and even back to work in at least a week (Memon et al, 1999, p. 849; Ammori et al., 2003, p. 304).

Several factors could have caused shoulder pain after the pain had undergone laparoscopic cholecystectomy. These causes include;

• The adverse effects of carbon dioxide gas (Kandil & El Hefnawy, 2010, 679)
• The negative impact of peritoneal stretching (Esmat et al, 2006, p. 1972)
• Irritation caused to the diaphragm
• Possible injury to the diaphragm
• Possible abduction of the shoulder during operation

During operation – laparoscopic surgery – carbon dioxide is usually injected via a special needle below the navel to insufflate the pelvic cavity giving the surgeon a better view of the organs in the area (Berberoglu et al., 1998, p. 274). Following this type of surgery, the patient may experience pain in the shoulder which could be mild, moderate, or severe.

As indicated previously, the diaphragm and the shoulder have a common nerve supply which is mainly the phrenic nerves and they serve the neck, the lungs, and the heart areas as well as the diaphragm. When the diaphragm is irritated and caused to experience some contractions when breathing, the shoulder pains. The pain is referred upwards via the nerve networks hence the shoulder tip pain (Chun-Chang et al, 2008, p. 487).

Besides inflating the cavity, the gas causes a physiological impact on the peritoneal tissues of the abdomen (Vezakis et al., 1999, P. 891). Recent studies have determined that diaphragm irritation was due to the death of cells when the gas temperatures change from 21c and also because of the drying effect of C02 at 0.0002% (Slim et al., 1999, p. 1113). This is the same concept as to how cold wind causes the skin to freeze in winter, cold gas in laparoscopy causes the death of peritoneal cells, therefore, causing the shoulder to feel pain.

Discriminate

Since the blood pressure was in the normal range, there was no need to raise alarm over the condition of the patient therefore hypertension was ruled out. The patient could be able to walk without vertigo, therefore, satisfied the nurse as ready for discharge. Having initially recorded severe pain at a VAS of 6, further analgesic therapy was advised.

It is only the shoulder pain that restricted Olcay’s discharge. There are several ways that the effects of C02 can be reduced in the future. Currently, surgeons do not often carry out processes of removing the gas when they are finishing the operation. Processes like to heat up and humidify C02, use local anesthetics and perform gasless operations effectively alleviate the effects of the gas (Hamza et al., 2005, p. 6).

There are several ways of reducing the pain that comes after the surgery but ht common one has been the use of simple analgesics (Sarli et al., 2000, p. 1162). However, I will use local anesthetic drugs for their analgesic effect. This pain can be relieved by a bilateral rectus sheath block which is carried out above the umbilicus by use of 0.25% bupivacaine by injecting 15ml on each side (Swami et al., 2004, p. 654).

Total pain relief can be attained by applying local anesthesia under the diaphragm using a special device or a sub-phrenic catheter. Shoulder pain may be persistent but pain management by use of lignocaine or bupivacaine administered i.p. (Gharaibeh & Al-Jaberi, 2000, p. 139), has been effective in many patients (Sarli et al., 2000, p. 1162).

The local anesthetics help to relieve general pain and are sometimes not effective in certain patients with shoulder tip pain following cholecystectomy. This could be the reason why the pain persisted in Olcay’s case despite administration of fentanyl hence necessitating admission. I will also use moistened heat packs to warm up the abdomen (Hamza et al., 2005, p. 6) so that the gas effect on the diaphragm is alleviated.

There are several other methods of decreasing the occurrence and severity of shoulder pain after laparoscopy operation. I would also perform postoperative sub-diaphragmatic suction to alleviate irritation and therefore reduce pain sensation in the shoulder. Regional anesthesia is also recommended around the peritoneal region as they help reduce general pain. However, studies on this intervention have given mixed results yet it is still used.

Issues of interest regarding the pain would be to monitor the area where pain is felt like right shoulder tip, the frequency of the pain which could be intermittent, sporadic, very often or continuous (Critchlow & Paugh, 1999, p. 1091). The severity is also rated on the VAS scale and also related to the use of analgesics to relieve the pain (Robinson et al., 2002, p. 516). Sometimes pain is relieved easily by analgesics sometimes it can be so severe that the analgesics cannot relieve the pain.

The things that aggravated the pain are supposed to be monitored closely which include taking deep breaths, eating, drinking, general body movement and certain shoulder movements (Critchlow & Paugh, 1999, p. 1091). There are also some relieving factors that are dealt with and they include using painkillers, lying on the bed, moving around, local application of heat (Sajid et al., 2008, p. 542), and in standing position.

I will also carry out humidification of the gas to relieve pain as this process has been proved to be effective as well. There are a number of clinical trials that have been done and the results indicate that when the PARU nurse warms up and humidifies the gas, intra-operative hypothermia is reduced. Consequently, this caused relieve of pain and enhance post operative process of recovery.

The laparoscopy cholecystectomy is regarded as a major operation and therefore has to be conducted in the operating room of a medical facility (Cuesta et al., 2008, 1212).

Depending on the details of the medical condition and the gall bladder problem, the doctors decide whether the patient will be treated as an outpatient or will be admitted for an overnight stay (Vuilleumier & Halkic, 2004, p. 739). Whichever the case, the patient will still need to report to the hospital in the morning the day of operation and subsequent visits for check up and monitoring (Ammori et al., 2003, p. 304).

Laparoscopy is a very safe and efficient procedure that has a standardised guideline hence reproducible and readily available. The procedure can be performed effectively by trained laparoscopist and it is not technically demanding (Hawe et al., 2001, p. 99). The post surgery experience is often very uncomfortable one and this has caused increased need to have the discomfort reduced. Patients often complain of pain and irritation with shoulder pain being the most common compared to wound pain or damage to internal viscera.

Even the simplest surgical procedures require psychosocial support as this service is very important in giving the patients the confidence and hope to go through the surgery (Jorgensen et al., 2008, P. 468).

Psychiatric assessment before the surgery can be conducted is a common practice in laparoscopy but it is not an intensive process taking a very long period of time like six months. Many hospitals use nurses to give this support, where clinical and psychiatric nurses given mental support to the patient before undergoing the surgery so that the outcomes may not be affected by patient’s emotional state of mind (Tacchino et al., 2008, p. 898).

The practitioners are highly skilled in performing the procedure which is an excisional treatment of gall bladder disease. The laparoscopists undergo advanced training to be able to carry out this procedure safety (Zegarra et al., 1997, p. 489).

Laparoscopic cholecystectomy is currently a standard treatment of cholecystitis and it is widely accepted because of the less scarring and decreased post-operative pain and that it has a very short hospital stay. Patients can be discharged on the same day they undergo the surgery. The goal of this process has been to offer convenience to the patients by reducing hospitalization time but optimizing patient safety as it is the definitive priority.

Ammori, B.J., Davides, D., Vezakia, A., et al., (2003). ‘Day Case Lapa­roscopic Cholecystectomy: A Prospective Evaluation of A 6-Year Experience,’ J Hepatobiliary Pancreat Surg , 10:303-8.

Bennett, A.A., et al., (2000). ‘Complication of “Dropped” Gallstones After Laparoscopic Cholecystectomy: Technical Consideration and Imaging Findings,’ Abdominal Imaging 25:190-193.

Berberoglu, M., et al., (1998). ‘The Effect of CO2 Insufflation Rate on the Post-laparoscopic Shoulder Pain,’ J Laparoendosc Adv Surg Tech A ; 8: 273-7.

Chun-Chang, Y., et al. (2008). ‘Shoulder Tip Pain after Laparoscopic Surgery Analgesia by Collateral Meridian Acupressure (Shiatsu) Therapy,’ A Report Of 2 Cases , Vol. 31, Issue 6, pp. 484-488.

Critchlow, J.T., Paugh, L.M., (1999). ‘Is 24-Hour Observation Necessary After Elective Laparoscopic Cholecystectomy?’ South Med J ; 92:1089-92.

Cuesta, M.A., Berends, F., & Veenhof, A., (2008) ‘The ‘‘Invisible Cholecystectomy’’: A Transumbilical Laparoscopic Operation without a Scar,’ Surg Endosc 22:1211–1213.

Esmat, M.E., Elsebae, M.M., Nasr, M.M., Elsebaie, S.B., (2006). ‘Combined Low Pressure Pneumoperitoneum and Intraperitoneal Infusion of Normal Saline for Reducing Shoulder Tip Pain Following Laparoscopic Cholecystectomy,’ World J Surg, 30(11):1969-73.

Gharaibeh, KI., & Al-Jaberi, T.M., (2000). ‘Bupivacaine Instillation Into Gallbladder Bed After Laparoscopic Cholecystectomy: Does It Decrease Shoulder Pain?’ J Laparoendosc Adv Surg Tech A ; 10: 137-41.

Hamza, M.A., et al., (2005). ‘Heated And Humidified Insufflation During Laparoscopic Gastric Bypass Surgery: Effect On Temperature, Postoperative Pain, And Recovery Outcomes,’ J Lap Adv Surg Tech , 15:6-12.

Hawe, A.J., et al., (2001). ‘Intraperitoneal Gas Drain To Reduce Pain After Laparoscopy: Randomized Masked Trial,’ Obstet Gynecol , 98 (1), P. 97-100.

Hussain, S. (2001). ‘Sepsis from Dropped Clips at Laparoscopic Cholecystectomy,’ Eur. J. Rad , 40:244-247.

Jorgensen, J.O., et al., (2008). ‘A Simple and Effective Way To Reduce Postoperative Pain After Laparoscopic Cholecystectomy , Australian And New Zealand,’ Journal Of Surgery, Vol. 65, Issue 7, pp. 466–469.

Kandil, T.S, & El Hefnawy, E., (2010). ‘Shoulder Pain Following Laparoscopic Cholecystectomy: Factors Affecting The Incidence And Severity,’ J Laparoendosc Adv Surg Tech A 20(8):677-82.

Memon, M.A., Deeik, R.K., Mafii, T.R., et al., (1999). ‘The Outcome of Unretrieved Gallstones in the Peritoneal Cavity during Laparoscopic Cholecystectomy,’ Surg. Endosc, 13:848-857.

Robinson, T.N., et al., (2002). Predicting Failure of Outpatient Laparo­scopic Cholecystectomy. Am J Surg 2002; 184: 515-8.

Sajid, M.S., et al., (2008). ‘Effect of Heated And Humidified Carbon Dioxide On Patients After Laparoscopic Procedures: A Meta-Analysis,’ Surg Lap Endosc Perc Tech ; 18 (6): 539-46.

Sarli, L., Costi, R., Sansebastiano, G., Trivelli, M., & Roncoroni, L., (2000). ‘Prospective Randomized Trial of Low-Pressure Pneumoperitoneum for Reduction of Shoulder-Tip Pain Following Laparoscopy,’ Br J Surg 87: 1161–5.

Slim, K., et al., (1999). ‘Effect Of CO2 Gas Warming On Pain After Laparoscopic Surgery: A Randomized Double-Blind Controlled Trial,’ Surg Endosc 13: 1110-4.

Swami, A., et al., (2004). ‘Is Intraperitoneal Levo-Bupivacaine With Epinephrine Useful For Analgesia Following Laparoscopic Cholecystectomy? A Randomized Controlled Trial,’ Eur J Anaesthesiol ; 21: 653-7.

Tacchino, R., Greco, F., & Matera, D., (2008) ‘Single-Incision Laparoscopic Cholecystectomy: Surgery Without A Visible Scar,’ Surg Endosc 23:896–899.

Vezakis, A., et al., (1999). ‘Randomized Comparison between Low-Pressure Laparoscopic Cholecystectomy And Gasless Laparoscopic Cholecystectomy,’ Surg Endosc ; 13: 890-3.

Vuilleumier, H., & Halkic, N., (2004). ‘Laparoscopic Cholecystectomy As A Day Surgery Procedure: Implementation and Audit of 136 Consecutive Cases in A University Hospital,’ World J Surg 28:737-40.

Yeh, C.C et al., (2008). ‘Shoulder Tip Pain After Laparoscopic Surgery Analgesia By Collateral Meridian Acupressure (Shiatsu) Therapy: A Report Of 2 Cases,’ 31(6):484-8.

Young, J., & O’Connell, B., (2001). ‘Recovery Following Laparoscopic Cholecystectomy In Either A 23 Hour Or An 8 Hour Facility,’ Journal of Quality in Clinical Practice , Vol. 21, Issue 2, pp. 2–7.

Zegarra, R.F., Saba, A.K., & Peschiera, J.L., (1997). ‘Outpatient Lapa­roscopic Cholecystectomy: Safe and Cost Effective?’ Surg Laparosc Endosc 7:487–90.

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Bibliography

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