Clinical reasoning is often considered as the most important skill that needs to be practiced by every nurse. It can be explained as the skill which is required by the nurses to help the nurses to develop a thinking process and an associated procedures so that they can arrive at a reasonable decision mainly concerning the not only the prevention of the disorder of the patient but also the diagnosis and clinical treatment of the specific patients (Forsberg et al., 2014). A proper and well directed clinical reasoning helps the nurse to critically analyse the history of the patient. This should be followed by proper conductance of the physical exam as well as the advising of the of the correct laboratory tests. These in clinical reasoning are followed by the designing safe and also effective treatment regimens and various types of preventive strategies so that the best quality care can be provided to the patient (Zamani et al., 2017). This would help the patient to recover early thereby resulting in less strain on not only the resources of the patients but also the healthcare sectors. The essay will first describe the importance of the clinical reasoning in nursing followed by the entire cycle of clinical reason and depicting the reflection of my work practices indicating its importance.
In order to perform the treatment of a patient clinical reasoning should be applied by the nurse as it helps the nurse to provide the best quality treatment by usually performing the important steps of clinical reasoning. The steps mainly involve the collection of proper data from the cues of the patients. This is then followed by processing the information according the critical thinking ability and then coming to an understanding of the patient problem or the situation that were the main causative factor (Alfaro-LeFevre, 2015). After that the nurse should plan and then implement the intervention with her knowledge and skill and accordingly evaluate the outcomes. The last step of an effective clinical reasoning process is the reflection of the nurse in order to understand the extent of her learning and to work on it.
One might raise a question that why such a skill is found to be advantageous for a nurse. This can be achieved by the explanation that follows. Nurses are often held responsible for the significant proportion for nursing judgements that they need to undertake along with the decisions made in different healthcare conditions. They tend to engage themselves in various multiple clinical reasoning episodes each and every day. Therefore it often becomes important to develop the ability to respond to the various challenging episodes which they have to confront everyday and which tend to change with every patient (Dicenso, Guyatt & Ciliska, 2014). Thereby for facing such challenges every day, only having psychomotor skills and knowledge are not enough to handle such situations. Sophisticated thinking skills also need to be developed which have a positive impact on the interventions decided for the patient.
Health Authority of Abu Dhabi has put forward a number of competencies which denote that if attained properly will result in best practise for mankind. Herein also it can be suggested that in order to adapt to the competencies for the best practice, the nurses should use their clinical reasoning ability to perform each of the competencies successively. Management of the nursing care is described by HAAD entirely with helps to promote optimum health and well being that gives the best performance outcomes. Each of the performance outcomes described by HAAD actually denotes the result of effective critical reasoning only. Other competencies mainly involve the promotion of the environment that helps in maximisation of patient safety (“Scope of Practice for Registered Nurses”, 2017). Clinical reasoning ability also helps to maintain the competency that governs the promotion of the patient’s psychological as well as physiological integrity. Other standards like the maintenance of ethical practice are also intricately associated with ethical practices, maintenance of professional ethical standards, collaborative approach with teams and also in professional development. The better the nurses ability to develop clinical reasoning, each and every of the activities will get enhanced in quality that will in turn help them to maintain each of the competencies in best of the manners.
There are many instances which shows that decision making in case for the treatment of the patients often remain based on professional knowledge and also in judgements in situations where a perfectly right solution can never be achieved due to various dilemma and confusions due to lack of proper experience and other factors. Often textbook learning and research knowledge prove to be insufficient to solve a newly rising problem where critical thinking ability of the nurse can only be the last resort for the nurse to actively protect the patient with danger (Capellati et al., 2014). Often this intervention taken for a particular patient may not be suitable for another patient with similar symptoms which can be only helped by critical clinical reasoning than theoretical knowledge. Therefore it has often acted as integral part of the treatment provided by the nurse for the patient.
There are basically five rights by which the clinical reasoning cycle has been linked. These five important rights are the ability to collect the right amount cues, taking the right action, for the right patient, at the right time after analysing the right reason, the nurse who maintains the five important rights for the clinical reasoning have fewer chances to get entangled into any dilemma or confusion (Ironside, McNelis & Ebright, 2017).
The very first step of clinical reasoning cycle when employed in a psychiatric background comprises of assessing the patient’s situation. For example in case of schizophrenia, a rather interesting mental illness, the consideration of the patient’s mental condition is of vital importance (Ashby et al., 2013). A schizophrenic has a rather creative mind, albeit detrimental but creative nonetheless, and in order to help the patient it is very important to learn how the wheels in his brain move (Chaffey, Unsworth & Fossey, 2012). The second step which mainly involves the collection of information along with cues, the step mainly includes the reviewing along with the analysis of the different current information which might come in the form of the patient history, their charts, handover reports and also the results which have been found out through the different investigations (Ashby et al., 2013). The best method to collect genuine information of a schizophrenic patient is to engage him in a fruitful conversation, something that does not threaten him, or provoke the unrealistic reaction. Communicating with a schizophrenic patient can be very challenging, and the health care professionals must be very careful at all times. It will also help to gather new information which is mainly obtained after proper assessment of the patient is done (Phillips, Duke & Weerasuriya, 2017). The following step should be processing the collected information; the responsibility of a psychiatric ward nurse is to analyze the information collected of the patient with the help of their knowledge about the disease and possible treatment plan (Charlin et al., 2012). This may cover pathophysiology, epidemiology, context of care, culture and many others, physiology, therapeutics. Proper interpretation of the severity of the patient is vital for an optimal diagnosis, this should include assessment of the symptoms of the patient using different tools of psychiatric help (Delany & Golding, 2014). The assessment tools available in market that can be used are the Brief psychiatric rating scale (BPRS), positive and negative syndrome scale (PANSS), scale for the assessment of negative symptoms (SANS). The next phase is the discrimination phase, narrowing down the information gathered by differentiating the different relevant and the irrelevant cases and recognising the inconsistencies (Bulman & Schutz, 2013). Her next movement will mainly involve the drawing of relationships between the various cluster cues that can be established from clearly identifying the patterns and the different symptoms with the diseases. The next step along the line is drawing proper inferences from the relations made between the different cluster cues (Dreifuerst, 2012).
In case of clinical diagnosis, the last but most important step is the identification of the problem, the causes and the effects that has the led the patient to where he is and characterizing the symptoms to arrive at a conclusion based on which the treatment plan will follow. Articulating an optimal treatment plan for a schizophrenic patient must start with the establishment of goals (Finkelman, 2015). A schizophrenic may need a variety of different treatment options, antipsychotic medication, or psychological therapies and counselling. All these broad spectrum options have different types and choices, and this is the step where the decision s made about the best plausible treatment option for the patient under consideration. Followed by the construction of a treatment plan, the next step for the nurse is to take adequate actions as mandated by the treatment plan (Keltner, 2013). This step mainly involves the selection of the pathway of intervention among a number of alternatives available and for this it involves critical thinking ability. Followed by the successful implementation of the interventions as per the treatment plan, the next step of the clinical reasoning cycle mainly involves the evaluation of the outcomes that have resulted from the interventions applied (Sniderman et al., 2013). The best method to assess the efficacy of the interventions applied can be the self reflection, questioning the techniques applied, their efficacy and whether some other technique can be followed that could yield better and easier outcome. This is an essential step for a nurse to learn from her mistakes and take notice of her excellence which will help her progress through her career. Reflective practice is a vital tool in a profession like health care as it evaluates the practice and its efficiency and broadens the horizon of practice scope for a nurse including the new knowledge and learning that the nurse will gather every single day through reflective practice (Delany & Golding, 2014).
Reflection is often considered to be a very important component that is extremely significant for the development of autonomous, critical and also different advanced practitioners. Nurses who develop the capability of effectively reflect on their experiences that are obtained from their every day practices are researched to perform enhanced nursing care. They tend to form a better understanding of the different actions that they take during their practices and these in turn tend to help in professional skill enhancements (Howatson-Jones, 2016). It basically helps a nurse with critically examining her own actions and functions with an outcome of effective development of their own practices as well as the enhancement of critical reasoning ability and also clinical knowledge. However, in order to develop the ability to critically reflect on one’s own practice, the nurse need to be harbouring the qualities like open-mindedness, willingness to accept, courageousness and also should possess the capability of ac ting on criticisms. These are often very necessary for a nurse as the presence of these attributes make the reflection effective.
While reflecting on my own practice about the skill of clinical reasoning, I would first try to point out a scenario which had shown the various positive and the negative aspects of the knowledge that I have developed from my practice days. I would take the help of the reflective cycle as proposed by Gibbs in the year 1988. This cycle would help to evaluate my experience by taking out each and every important aspect in details.
While trying to critically reflect upon the practices on the basis of the knowledge of the critical reason ability, the entire incident would be placed according to Gibbs idea of reflection that will help to show the mistake I made and how I can learn from the mistake and in return not repeat the mistakes next time in future.
The first step of the Gibb’s model is the description of the entire incident. A patient was brought to our hospital on Monday morning at 10 o clock sharp in the morning. The patient’s name was Sophia Brown and was 22 years of age. She was mainly admitted to the ICU department of the hospitals mainly due to a catatonic state. Her history as defined by her mother covered treatments for schizophrenia. Under the guidance of my mentor, I undertook diagnosis of her which showed that she was also having symptoms of tachycardia and was also diaphoretic along with being tachypnoeic and febrile.
The second step of Gibbs ‘model tell us to describe the feelings that we developed at that particular time. After my thorough analysis I came to the conclusion that as the observations were outside the normal limits slightly, I thought that the cationic stage was mostly due to the anxiety that accompanies Sophia’s type of illness. However, while moving through her files I noticed that she had recently undergone the use of antipsychotic drug, clozapine and was unable to relate properly what type of interventions should be planned by me as I never have faced such symptoms in a patient.
The thirds step is the evaluation stage. The patient under the advice of my mentor was shifted to another hospital where she required specialised treatment. Under the expertise of my mentor I came to understand the main mistakes that I had made while performing the different steps of clinical reasoning. At the very beginning the main mistake that I had conducted was that I jumped into a conclusion without considering g the alternatives that might have resulted in the poor condition of the patient. At the very start I had made a clinical reasoning error when I considered the patient as psych by seeing her mentally ill. This prevented me from scrutinising the bigger picture because I had already made a preconceived notion. I had completely neglected the symptom of her raising temperature which is an important part of clinical reasoning cycle. I did not consider the temperature rise as it did not fit my theory of anxiety which I was proceeding with. This evaluation let me realise that I had yet not mastered the ability of clinical reasoning for which I required more experience and critical thinking ability to master it.
Analysis part helped me to understand that the occurrence of the catatonic stage in the patient was mainly the result of the antipsychotic drugs which she had taken prior to the condition of the present. I investigated the information of the file and also carried on different evidence based literature and reviews that gave me a large number of information. I understood that her condition was mainly due to the neuroleptic malignant syndrome (NMS) that is life threatening and had mainly occurred due to the therapy that she had undertaken. The main symptoms of this mainly included tachypnoea, muscle rigidity, tachycardia, fever and also diaphoresis. If I had properly analysed the patient, I would have found that her creatine kinase level had shot up which shows symptoms of NMS.
In the conclusion part of the cycle I would mainly describe the other things that I could have been done. This would mainly include not getting overconfident about my diagnosis and follow each of the clinical reasoning steps effectively. If is had done so, I could have realised the main disorder and taken steps accordingly.
When I tried to reflect my practise, I understood that the errors were done by me mainly due to my over enthusiasm which affected my ideas. I realised that I have a bad habit of jumping into conclusions to solve issues quickly which is strictly against the rules of clinical reasoning cycle. The clinical errors that I made were interconnected and showed symptoms of biased judgement. From next time onwards, I would follow every steps of clinical reason which would include analysis of clinical pathways, proper collection of information, making proper care plans methodically and enhancing my practise. I will never jump into conclusions and be always aware of my cognitive process.
On a concluding note, it can be said that the steps of clinical reasoning utilizes cognitive logical thinking and articulates sets of strategies that will be optimal for the patient with a more realistic approach. The framework of clinical reasoning not only helps the nurse understand the exact condition and needs of the patient but also helps her to device strategic intervention that will not only help the patient progress through their recovery path but also help the nursing professional to gain more applicative experience in the field. It can be considered that this revolutionary invention in the clinical practice has come as a blessing that will help the health care professionals flourish along with elevating the standards of the health care facility.
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