Importance of clinical reasoning cycle in nursing care

Clinical reasoning cycle can be considered as an essential element of nursing care for the provision of a client-centered care because it has the power to determine the outcome of the patient care (Australian Learning and teaching cycle. 2018). Poor clinical reasoning skill has been found to deliver accurate and satisfactory health care (Durning et al. 2013).  Drawing on the previous case study, Ms. Ness Ms Ness was brought to the Medical unit with a chief complaint of exacerbation of COPD. She had a history of Type 2 diabetes for which she was taking antidiabetic medications. On 17th of December 2018, she was about to be  discharge d as her assessments were found to be alright and she was found to be medically stable; however, in the afternoon the student nurse conducted an OBS round and found that Ms Ness looked more pale and clammy than the usual . In addition, she was anxious, weak and agitated. The nurse did not examine the signs and symptoms presented by the patient as these are common manifestations of COPD. In this regard, it was found that before breakfast, Ms Ness’ BGL was significantly low for her. The nurse in the morning took the blood glucose level of the patient; however, the nurse overlooked to interpret the reading and did not take any patient cues. As such, the morning nurse gave the medication without realizing that the patient BGL was low and the patient had a poor oral intake.

In this case study, I will discuss about two errors that I have encountered while caring for Ms. Sweet Ness. One of the errors that has been identified is the unpacking principle and the premature bias, while the entire clinical reasoning was taking place.

The nurse has made an error in the processing of the information is visible from the fact that  the nurse in the morning did not consider Ms. Ness low blood glucose level (5.3 mmol) before the administration of the antidiabetic drug 5.3 mmol of blood sugar level can be considered much less in patients with T2D. The processing of the information recognizes changes in the condition of the patient and failure to asses any changes in the patient condition might lead to adverse condition (Bonds et al 2014). Premature closure is again a diagnostic error that is caused in a decision making process, where a diagnosis is accepted before it has been diagnosed fully (Saposnik et al. 2016). This error causes for a high proportion of missed diagnosis. In many cases, the decisions are made too early and can be linked to missed diagnosis (Norman et al. 2017). It is evident from the case study that patient’s skin had become clammy and the patient was displaying weakness and agitation, which was mistakenly considered as the signs and symptoms of COPD, but later on it was found that it was due to the hypoglycemia.  Furthermore, Errors in collecting the cues has also been found in this clinical encounter.

Case study: Errors made in caring for a patient with COPD and Type 2 diabetes

Unpacking principle is a type of clinical reasoning error identified by Levett Jones that occurs on failure to collect all the relevant cues is establishing a differential diagnosis that may result in significant possibilities being missed (Australian Learning and teaching cycle. 2018).  Considering Ms. Ness’ low blood glucose level, the nurse did not go for further assessment or did not even as whether the patient had her breakfast before giving any kind of antidiabetic medications. There are certain diabetic medicines that should be taken with meals it increases insulin efficiency and to avoid the gastrointestinal effects (Rates 2014). It can also be known from the case study that just before commencing the discharge procedure, the nurse that Ms. Ness looked Pale and Clammy and Pale than usual. Ms. Ness justified this with the reason that she skipped breakfast and dinner. This should not have been the case; a caregiver might have been appointed who could have looked after Ms. Ness, such that she does not skip meals or medications. Errors in the collection of cues leads to faulty decision making among the clinicians (Bordini et al. 2015). Saposnik et al. (2016) have stated that the accuracy of the judgment depends upon the how the cues are used.  

The accurate detection of the cue clusters in order to indicate possible deterioration in the patient  can be considered as an important aspect of the decision making process. The information processing theory describes the cognitive processing as the tie of making decisions. Norman et al. (2017) have worked on the cognitive psychology of the clinical reasoning. The diagnosis starts with the acquisition of the data by the history taking and the clinical examination. The health experts analyses the data subconsciously for framing or contextualizing the problems of the patient. Then they use various abstract linkages for transforming the individual clinical findings in to a coherent clinical syndrome that trigger one or more diagnostic ideas (Bordini et al. 2015). It is evident from the case study that Ms. Sweet Ness was admitted to the emergency department due to COPD exacerbations. While collecting the  cue, it was noticed that the oxygen saturation of the patient was quite less, compared to the standard value,  but no information about this problem has been focused on , while working on this case patient. The geriatric assessment prior to the discharge also includes assessment of the airways and the breathing pattern.

Types of clinical reasoning errors identified in the case study

The adverse outcome of the error depends upon the severity of the processing errors. Taking anti-diabetic drug along with skipping of the meals might cause hypoglycemia, which can bring about life threatening condition in patients. The case study already reveals that Ms. Ness was disoriented and confused with slurred speech, which might have been caused due to hypoglycemia. Most of the reasoning errors are avoidable and hence in this case the nurse in charge might have assessed Ms. Ness, whether she is abiding by the nutritional regimen of not before any further administration of the Anti-diabetic medicine. Finding Ms. Ness with pale and clammy skin surely is an indicator of nursing mismanagement and lack of a proper geriatric assessment team. Paleness, clamminess and dizziness are some of the common symptoms of hypoglycemia. Such a situation would not have arisen, had the nurse in charge done a proper assessment.

Conclusion

Several intervention strategies can be adopted for mitigating the risk of clinical reasoning error.  Incorrect processing of the information or missing cues at the time of history taking might lead to adverse events and can even cause deaths in patients (Graber et al. 2016). In the clinical encounter, the nurses failed to keep a note, whether the patient has had breakfast before taking the medications and failed to consider the abnormally low BGL in the patient before the administration of the antidiabetic drug. I felt nervous as such, conditions might deteriorate the condition of the patient, when the patient is ready for the discharge. In order to avoid clinical errors like unpacking principles and premature bias,  it is necessary to be in constant interaction with the patient. As a nurse, I should always be willing to investigate and consider the alternative possibilities. It has to be considered that the patients is disclosed with all the information.  Furthermore, being a nurse it is essential that I observe that my patients are having meals on time or are adhering to the medication regimen. However, I wish to take part in training and workshops meant for the professional development, which will enhance my clinical expertise.

I will always obtain feedback from my peers and the seniors, as I believe that decision-making process would be improved if seasoned and respected peers review my nursing actions. I intend to improve and brush my knowledge over clinical handovers in order to facilitate a seamless transition during the shifts. Documentation of the patient records is another part of the cue collection. Both experiential teaching and didactic teaching is helpful to do that. Clinical audits has always been helpful in the continuous improvement of the strategies. Hence, feedbacks through various clinical audits are necessary for preventing any near misses (Coxon and Rees 2015). Focusing on the clinical audits would be helpful in improving my professional standards. My actions should not be affected by any previous misconceptions. Maintenance of a continuity of care is necessary for facilitating awareness from the past mistakes. Again, I believe that intense research and lifelong learning is necessary to have an improved knowledge regarding the various types of error theories and the skills required in metacognition (Coxon and Rees 2015). It is necessary to work in a slower and a methodical way in order to reduce the errors. Self- analyzing is necessary to understand where errors can occur (Singh et al. 2016). As a nurse, I should be more self-regulated and vigilant about my own actions. Resilience and mindfulness is necessary for the nurses in order to collect cues and process information during the clinical reasoning process Coxon and Rees,  2015). The carers, patients and the families should be mindful regarding the circumstances, which can trigger the chances of clinical errors. Too much workload and less amount of nursing staffs might cause the novice nurses to miss important cues at the time of the assessment. However, I intend to do more evidence-based research in order to improve my clinical reasoning skills as that will help to link the cases with the underlying pathophysiology of the disease.

References

Australian Learning and teaching cycle. 2018. Clinical-Reasoning-Instructor. Access date: 25.1.2019. Retrieved form: https://www.utas.edu.au

Bordini, B.J., Stephany, A. and Kliegman, R., 2017. Overcoming diagnostic errors in medical practice. The Journal of pediatrics, 185, pp.19-25.

Coxon, J. and Rees, J., 2015. Avoiding medical errors in general practice. Trends in Urology & Men’s Health, 6(4), pp.13-17.

Durning, S. J., Artino Jr, A. R., Schuwirth, L., & van der Vleuten, C. (2013). Clarifying assumptions to enhance our understanding and assessment of clinical reasoning. Academic Medicine, 88(4), 442-448.

Graber, M.L., Kissam, S., Payne, V.L., Meyer, A.N., Sorensen, A., Lenfestey, N., Tant, E., Henriksen, K., LaBresh, K. and Singh, H., 2012. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf, 21(7), pp.535-557.

Norman, G.R., Monteiro, S.D., Sherbino, J., Ilgen, J.S., Schmidt, H.G. and Mamede, S., 2017. The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking. Academic Medicine, 92(1), pp.23-30.

Rates, R.H., 2014. Reducing/Preventing Hypoglycemic Risk Through Evidence-Based Practice.

Saposnik, G., Redelmeier, D., Ruff, C. C., and  Tobler, P. N. 2016. Cognitive biases associated with medical decisions: a systematic review. BMC medical informatics and decision making, 16(1), 138

Singh, H., Graber, M.L., Kissam, S.M., Sorensen, A.V., Lenfestey, N.F., Tant, E.M., Henriksen, K. and LaBresh, K.A., 2012. System-related interventions to reduce diagnostic errors: a narrative review. BMJ Qual Saf, 21(2), pp.160-170.

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