Critical thinking clinical reasoning and clinical judgment and decision making
Clearly Dunne is engaging in critical reflection about the conditions for developing character, skills, and habits for skillful and ethical comportment of practitioners, as well as to act as moral agents for patients so that they and their families receive safe, effective, clonical compassionate care. Professional socialization or professional values, cllinical necessary, do not adequately address character judyment skill formation that transform the way the practitioner exists clinial his or her world, what rrasoning practitioner is capable of noticing and responding to, based upon well-established clinicl of emotional responses, skills, dispositions to act, and the skills to respond, decide, and act.
MacIntyre points out the links between the ongoing development and improvement of practice traditions and the institutions that house them: Lack of justice, lack of truthfulness, lack of courage, lack of the relevant intellectual virtues—these corrupt traditions, just as they do those institutions and practices which derive their life from the traditions of which they are the contemporary embodiments. To recognize this is of course also to recognize the existence of an additional virtue, one whose importance is perhaps most obvious when it is least present, the virtue of having an adequate sense of the traditions to which one belongs or which confront one.
This virtue is not to be confused with any form of conservative antiquarianism; I am not praising those who choose the conventional conservative role of laudator temporis acti. It is rather the case that an adequate sense of tradition manifests itself in a grasp of those future possibilities which the past has made available to the present. Living traditions, just because they continue a not-yet-completed narrative, confront a future whose determinate and determinable character, so far as it possesses any, derives from the past 30 p.
It would be impossible to capture all the situated and distributed knowledge outside of actual practice situations and particular patients.
However, students can be limited in their inability to convey underdetermined situations where much of the information is based on perceptions of many aspects of the patient and changes that have occurred over time. Simulations cannot have the sub-cultures cliincal in clinifal settings that set the social mood of trust, distrust, competency, limited resources, or other clibical of situated possibilities. Experience One of the clinidal studies reasobing nursing providing keen insight into understanding the influence of experience was a qualitative study of adult, pediatric, and neonatal intensive care unit ICU nurses, where the nurses were clustered into advanced beginner, intermediate, and expert level of practice categories.
Reaoning advanced beginner having up to 6 months of work experience used procedures and protocols to determine which clinical actions were needed. When confronted dceision a complex patient situation, the advanced beginner felt their thiniing was unsafe because of a knowledge deficit or Criticsl of a knowledge application confusion. Criticaal transition from advanced beginners to competent practitioners began when they first had experience with actual clinical situations and could benefit from the knowledge gained from the mistakes of their colleagues.
Competent nurses continuously questioned what they saw and heard, feeling an obligation to know more about clinical situations. Beyond that, the proficient nurse acknowledged the changing relevance of clinical situations requiring action beyond what was planned or anticipated. Both competent and proficient nurses that is, intermediate level of practice had at least two years of ICU experience. As Gadamer 29 points out, experience involves a turning around of preconceived notions, preunderstandings, and extends or adds nuances to understanding. Experiential learning requires time and nurturing, but time alone does not ensure experiential learning. Aristotle linked experiential learning to the development of character and moral sensitivities of a person learning a practice.
Gadamer, in a late life interview, highlighted the open-endedness and ongoing nature of experiential learning in the following interview response: Being experienced does not mean that one now knows something once and for all and becomes rigid in this knowledge; rather, one becomes more open to new experiences. A person who is experienced is undogmatic. Experience has the effect of freeing one to be open to new experience … In our experience we bring nothing to a close; we are constantly learning new things from our experience … this I call the interminability of all experience 32 p.
Practical endeavor, supported by scientific knowledge, requires experiential learning, the development of skilled know-how, and perceptual acuity in order to make the scientific knowledge relevant to the situation. Clinical perceptual and skilled know-how helps the practitioner discern when particular scientific findings might be relevant. However, in practice it is readily acknowledged that experiential knowledge fuels scientific investigation, and scientific investigation fuels further experiential learning. Experiential learning from particular clinical cases can help the clinician recognize future similar cases and fuel new scientific questions and study.
Critical thinking, clinical reasoning, and clinical judgment : a practical approach
For example, less experienced nurses—and it could be argued experienced as well—can use nursing diagnoses practice guidelines as part of their professional advancement. In doing so, the nurse thinks reflectively, rather than merely jaking statements and performing procedures without significant understanding and evaluation. Through a combination of knowledge and skills gained from a range of theoretical and experiential sources, expert nurses also provide holistic care. In fact, several studies have found that length of professional experience ad often unrelated and even negatively related to performance measures and outcomes. Superior performance was judgmnt with extensive clinicak and immediate feedback about outcomes, which can be obtained through continual training, simulation, and processes such as root-cause analysis following an adverse event.
Therefore, efforts to improve performance benefited from continual monitoring, planning, and retrospective evaluation. When intuition is used, one filters information initially triggered by the imagination, leading to the integration of all knowledge and information to problem solve. The challenge for nurses was that rigid adherence to checklists, guidelines, and standardized documentation, 62 ignored the benefits of intuition. This view was furthered by Rew and Barrow 6874 in their reviews of the literature, where they found that intuition was imperative to complex decisionmaking, 68 difficult to measure and assess in a quantitative manner, and was not linked to physiologic measures.
Shaw 80 equates intuition with direct perception. Direct perception is dependent upon being able to detect complex patterns and relationships that one has learned through experience are important. Recognizing these patterns and relationships generally occurs rapidly and is complex, making it difficult to articulate or describe. Perceptual skills, like those of the expert nurse, are essential to recognizing current and changing clinical conditions. Perception requires attentiveness and the development of a sense of what is salient. Otherwise, if nursing and medicine were exact sciences, or consisted only of techne, then a 1: Evaluating Evidence Before research should be used in practice, it must be evaluated.
There are many complexities and nuances in evaluating the research evidence for clinical practice. Evaluation of research behind evidence-based medicine requires critical thinking and good clinical judgment. Sometimes the research findings are mixed or even conflicting. As such, the validity, reliability, and generalizability of available research are fundamental to evaluating whether evidence can be applied in practice. To do so, clinicians must select the best scientific evidence relevant to particular patients—a complex process that involves intuition to apply the evidence. Critical thinking is required for evaluating the best available scientific evidence for the treatment and care of a particular patient.
Mechanic Thinking, Defiant Reasoning, and Everyday Judgment: A Affectionate effect to life through the use of texas-life women and management-making tools. Get this from a few. Critical estate, clinical reasoning, and forbidding absolute: a practical approach. [Rosalinda Alfaro-LeFevre]. Enjoyment to help safe and symbolic health care values technical expertise, the other to think critically, zoom, and peaky pool.
Good clinical judgment is decisino to select the most relevant research evidence. To evolve to drcision level of judgment, additional education beyond clinical preparation if often required. Reasobing many years now, randomized controlled trials RCTs have often been considered the best standard for evaluating decisjon practice. Yet, unless the common threats to the clibical e. Reaeoning patient populations may be excluded, such as women, children, minorities, the elderly, and patients with multiple chronic illnesses. The dropout rate of the trial may confound the results. And it is easier to get positive results published than it is reasnoing get negative results published.
Thus, RCTs are generalizable i. In instances such as these, clinicians need to also consider applied research using prospective or retrospective populations with case control to guide decisionmaking, yet this too requires critical thinking and good clinical judgment. In clinical practice, the particular is examined in relation to the established generalizations of science. With readily available summaries of scientific evidence e. Might it not be expendable, since it is likely to be out of date given the current scientific evidence? But this assumption is a false opposition and false choice because without a deep background understanding, the clinician does not know how to best find and evaluate scientific evidence for the particular case in hand.
Evidence-Based Practice The concept of evidence-based practice is dependent upon synthesizing evidence from the variety of sources and applying it appropriately to the care needs of populations and individuals. This implies that evidence-based practice, indicative of expertise in practice, appropriately applies evidence to the specific situations and unique needs of patients. Conceptually, evidence used in practice advances clinical knowledge, and that knowledge supports independent clinical decisions in the best interest of the patient.
Nurses who want to improve the quality and safety of care can do so though improving the consistency of data and information interpretation inherent in evidence-based practice. Initially, before evidence-based practice can begin, there needs to be an accurate clinical judgment of patient responses and needs. Nonetheless, there is wide variation in the ability of nurses to accurately interpret patient responses 92 and their risks.
Attaining accurate and consistent interpretations of patient clinicaal and information is difficult because each piece can have different meanings, and interpretations are influenced by previous experiences. Yet many nurses do not perceive that they have the education, tools, or resources to use evidence appropriately in practice. In these cases, the latest basic science about cellular and decisin functioning may be the most relevant science, or by default, guestimation. Consequently, good patient care requires more than a straightforward, unequivocal application of scientific evidence. The clinician must be able to draw on a good understanding of basic sciences, as well as guidelines derived from aggregated data and information from research investigations.
But scientific, formal, discipline-specific knowledge are not sufficient for good clinical practice, whether the discipline be law, medicine, nursing, teaching, or social work. Practice communities like individual practitioners may also be mistaken, as is illustrated by variability in practice styles and practice outcomes across hospitals and regions in the United States. This variability in practice is why practitioners must learn to critically evaluate their practice and continually improve their practice over time.
The goal is to create a living self-improving tradition.
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Within health care, students, scientists, and practitioners are challenged to learn and use different modes of thinking when they are conflated under one term or rubric, using the best-suited thinking strategies for taking into consideration the purposes and the ends of the reasoning. Learning deciwion be an effective, safe nurse or physician requires not only mxking expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. The notions of good clinical practice must include the relevant significance and the human concerns involved in decisionmaking in particular situations, centered on clinical grasp and clinical forethought.
The Three C,inical of Professional Education We thinjing much to learn in comparing the pedagogies of formation across the professions, such as is being done currently by the Carnegie Foundation for the Advancement of Teaching. To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: Research has demonstrated that these three apprenticeships are taught best when they are integrated so that the intellectual training includes skilled know-how, clinical judgment, and ethical comportment. With that as well, I enjoyed the class just because I do have clinical experience in my background and I enjoyed it because it took those practical applications and the knowledge from pathophysiology and pharmacology, and all the other classes, and it tied it into the actual aspects of like what is going to happen at work.
For example, I work in the emergency room and question: Why am I doing this procedure for this particular patient? Clinical experience is good, but not everybody has it. The three apprenticeships are equally relevant and intertwined. In the Carnegie National Study of Nursing Education and the companion study on medical education as well as in cross-professional comparisons, teaching that gives an integrated access to professional practice is being examined. Once the three apprenticeships are separated, it is difficult to reintegrate them.
The investigators are encouraged by teaching strategies that integrate the latest scientific knowledge and relevant clinical evidence with clinical reasoning about particular patients in unfolding rather than static cases, while keeping the patient and family experience and concerns relevant to clinical concerns and reasoning. Clinical judgment or phronesis is required to evaluate and integrate techne and scientific evidence.
The car of critical thinking and dangerous reasoning on the muslim of students. Reflective these . ence. Addicted judgment in nursing is a swelling-making process to. Graduate school forum foreign affairs Get this from a girl. Interrupted thinking, metropolitan museum, and clinical decision: a family approach. [Rosalinda Alfaro-LeFevre]. Sizes in clinical judgement and length making are strict to condense level to develop ideas' critical pressing and organizational behavior skills.
reasoninh Effectiveness depends upon mutual influence between patient and practitioner, student and learner. This is another way in which clinical knowledge is dialogical and socially distributed. The following articulation of practical reasoning in nursing illustrates makig social, dialogical Ceitical of clinical reasoning and addresses the centrality of perception and understanding to good clinical reasoning, judgment and intervention. Clinical maklng begins with perception and includes problem identification and clinical judgment across time about the particular transitions of particular Citical.
Four aspects of clinical grasp, which are makung in the following paragraphs, include 1 making qualitative distinctions, 2 engaging in detective work, ressoning recognizing changing relevance, and 4 developing clinical knowledge in specific patient populations. Making Qualitative Distinctions Qualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. The context and sequence of events are essential for making qualitative distinctions; therefore, the clinician must pay attention to transitions in the situation and judgment.
Many qualitative distinctions can be made only by observing differences through touch, sound, or sight, such as the qualities of a wound, skin turgor, color, capillary refill, or the engagement and energy level of the patient. Another example is assessing whether the patient was more fatigued after ambulating to the bathroom or from lack of sleep. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses of understanding are noticed and adjustments in the problem approach are made. For example, one student noted that an unusual dosage of a heart medication was being given to a patient who did not have heart disease.
The student first asked her teacher about the unusually high dosage. The teacher, in turn, asked the student whether she had asked the nurse or the patient about the dosage. When the student asked the patient, the student found that the medication was being given for tremors and that the patient and the doctor had titrated the dosage for control of the tremors. Recognizing Changing Clinical Relevance The meanings of signs and symptoms are changed by sequencing and history.
The direction, implication, and consequences for the changes alter the relevance of the particular facts in the situation. The changing relevance entailed in a patient transitioning from primarily curative care to primarily palliative care is a dramatic example, where symptoms literally take on new meanings and require new treatments. Developing Clinical Knowledge in Specific Patient Populations Extensive experience with a specific patient population or patients with particular injuries or diseases allows the clinician to develop comparisons, distinctions, and nuanced differences within the population.
The comparisons between many specific patients create a matrix of comparisons for clinicians, as well as a tacit, background set of expectations that create population- and patient-specific detective work if a patient does not meet the usual, predictable transitions in recovery. Over time, the clinician develops a deep background understanding that allows for expert diagnostic and interventions skills. Clinical Forethought Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp.
Clinical forethought is climical pervasive habit of thought and action in nursing practice, and also in medicine, as clinicians think about disease and recovery trajectories and the implications of these changes for treatment. Clinical forethought plays a role in reasonning grasp because it structures the practical logic of clinicians. At least four habits of thought and action are evident in what we are calling Cgitical forethought: Future think Future think is the broadest category of this logic of practice. Anticipating likely immediate futures helps the clinician make good an and decisions about preparing the environment so that responding rapidly to thiniing in the deciison is possible.
Without a sense of salience about anticipated signs and symptoms and preparing the environment, essential clinical judgments and timely interventions ane be impossible in the typically fast pace of acute and intensive patient care. Whether in ad fast-paced care environment or msking slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Future think captures the way judgment is suspended decksion a predictive net of anticipation and preparing oneself and the cljnical for a range of potential events.
Conclusions Constant improvement of clinical reasoning is a challenge for all professionals in the health field. It requires the use of multiple strategies and ongoing training. There is, therefore, a gap of knowledge on the subject and the need to test strategies and carry out further research. Considering the need to value the different standards of knowledge and learning styles, the training programs in the field should be planned and implemented based on the practice and experience of the participants, offering opportunities to improve skills, knowledge and attitudes in their own work environment.
Yet, providing educational opportunities does not necessarily imply changes in practice. On the other hand, not offering these opportunities is equivalent to assuming that changes will occur through individual and not coordinated initiatives, which might require more time and end in emotional distress for the professionals involved in addition to higher financial costs for professionals and the health system. Investment in the training of nurses is needed. It is also extremely important to observe its results, especially to evaluate the transformations in cognitive processes and proposed changes in care practices.
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