Chapter 1 Clinical decision making and multiple problem spaces

In the second edition of this book we drew on our initial view of clinical reasoning as a process incorporating the elements of cognition, knowledge and metacognition, expanding this to place a greater emphasis on patient-centred care as the context for clinical reasoning. Practitioners were presented as interactional professionals (Higgs & Hunt 1999) whose effectiveness required interaction with their immediate and larger work environment, with the key players in that context, and with the situational elements pertinent to the patient and case under consideration. Health care was presented via a social ecology model as occurring within the wider sphere of social responsibility of professionals which requires practitioners to be proactive as well as responsive to changes in healthcare contexts (Higgs et al 1999).

In this opening chapter of the third edition we extend our previous examination of the nature of clinical reasoning and its context, drawing on our own research and that of colleagues and co-authors. We expand our interpretation of clinical reasoning from a process view, to explore clinical reasoning as a contextualized phenomenon (see also Chapters 2, 8). We extend consideration of the decision-making context from a focus on the immediate task environment of case management acting in the wider healthcare context to explore the multiple levels of the clinical decision-making space, or rather the multiple decision-making spaces, within which interactive reasoning and decision making occur (see Higgs 2006a, b).

In relation to clinical reasoning expertise, we extend the notion of an expert to encompass capability, professional artistry and patient-centredness; expertise is a journey rather than a point of arrival (see also Chapters 11 and 16). In examining and making explicit these aspects of clinical reasoning our goal is to make clinical reasoning more accessible for novices to learn, for experienced practitioners to portray, for educators to teach, for clinicians to practise and for researchers to explore.

UNDERSTANDING CLINICAL REASONING

In the 10 years since we produced the first edition of this book, we have retained our view that clinical reasoning is both simple and complex. Simply, clinical reasoning is the sum of the thinking and decision-making processes associated with clinical practice; it is a critical skill in the health professions, central to the practice of professional autonomy, and it enables practitioners to take ‘wise’ action, meaning taking the best judged action in a specific context (Cervero 1988, Harris 1993). Despite being straightforward and ‘simple’ this view is very broad; clinical reasoning is seen as permeating throughout clinical practice and as being the core of practice. The importance of understanding the complex nature of clinical reasoning is emphasized in the goal of developing tolerance of ambiguity and a reflexive understanding of practice artistry during health sciences education, as suggested by Bleakley et al (2003).

The complex view of clinical reasoning is embedded in its simplicity and breadth (Higgs 2006b). By encompassing so much of what it means to be a professional (autonomy, responsibility, accountability and decision making in conditions of uncertainty), clinical reasoning gains an inherent mystique. This complexity lies in the very nature of the task or challenge, faced by novice and expert alike, which is to process multiple variables, contemplate the various priorities of competing healthcare needs, negotiate the interests of different participants in the decision-making process, inform all decisions and actions with advanced practice knowledge, and make all decisions and actions in the context of professional ethics and community expectations. The mystique is most evident in the skill of the expert diagnostician who makes difficult decisions with seeming effortlessness, and in the professional artistry of the experienced practitioner who produces an individually tailored health management plan that addresses complicated health needs with humanity and finesse. To address and achieve these professional attributes clinical reasoning is much more a lived phenomenon, an experience, a way of being and a chosen model of practising than it is simply a process. To this end we adopt the following definition of this complex phenomenon:

Clinical reasoning (or practice decision making) is a context-dependent way of thinking and decision making in professional practice to guide practice actions. It involves the construction of narratives to make sense of the multiple factors and interests pertaining to the current reasoning task. It occurs within a set of problem spaces informed by the practitioner’s unique frames of reference, workplace context and practice models, as well as by the patient’s or client’s contexts. It utilises core dimensions of practice knowledge, reasoning and metacognition and draws on these capacities in others. Decision making within clinical reasoning occurs at micro, macro and meta levels and may be individually or collaboratively conducted. It involves metaskills of critical conversations, knowledge generation, practice model authenticity and reflexivity. (Higgs 2006b)

Of note in this definition is the term ‘clinical’. For some health professionals their workplace is not ‘clinical’, their clients are not patients, the focus of their role may be on health rather than illness, and the term ‘consultant’ rather than ‘practitioner’ may be more appropriate. To avoid clumsy expression of these alternative terms we use the terms clinical reasoning and clinical decision making below.

CLINICAL REASONING AND METASKILLS

Our previous model of clinical reasoning (Higgs & Jones 2000) was presented as an upward and outward spiral, a cyclical and a developing process. Each loop of the spiral incorporated data input, data interpretation (or reinterpretation) and problem formulation (or reformulation) to achieve a progressively broader and deeper understanding of the clinical problem. Based on this deepening understanding, decisions are made concerning intervention, and actions are taken. The process was described as including:

a the core dimensions of

• Knowledge. A strong discipline-specific knowledge base, comprising propositional knowledge (derived from theory and research) and non-propositional knowledge (derived from professional and personal experience), is necessary for sound and responsible clinical reasoning.

• Cognition or reflective inquiry. Cognitive or thinking skills (such as analysis, synthesis and evaluation of data collected) are utilized to process clinical data against the clinician’s existing discipline-specific and personal knowledge base in consideration of the client’s needs and the clinical problem.

• Metacognition. Metacognition or reflective self-awareness serves to bridge knowledge and cognition. It enables clinicians to identify limitations in the quality of information obtained, inconsistencies or unexpected findings; it enables them to monitor their reasoning and practice, seeking errors and credibility; it prompts them to recognize when their knowledge or skills are insufficient and remedial action is needed.

b the additional dimensions of

• mutual decision making, or the role of the client or patient in the decision-making process

• contextual interaction, or the interactivity between the decision makers and the situation or environment of the reasoning process

• task impact, or the influence of the nature of the clinical problem or task on the reasoning process.

These additional dimensions were included in recognition of the growing expectation by and of consumers that they play an active role in their own health care. The image of compliant, dependent patients is replaced by one of informed healthcare consumers who expect their needs and preferences to be listened to, who increasingly want to participate in decision making about their health, and who expect to take action to enhance their health. Alongside this ‘health rather than illness’ focus on the part of the consumer, there are increasing expectations of service and of quality and ownership of health programmes, due to economic factors such as an increasing reliance on ‘user pays’ funding strategies, within which consumers are indeed purchasing health care. Similarly, caregivers need and wish to play a greater role in health management and decision making.

To these dimensions we now add four meta-skills:

• the ability to derive knowledge and practice wisdom from reasoning and practice (see Chapter 14). Reasoning plays a significant role in the acquisition of knowledge (Lawson et al 1991)

• the location of reasoning as behaviours and strategies within chosen practice models, each with an inherent philosophy of practice (see Chapters 3, 11)

• the reflexive ability to promote positive cognitive, affective and experiential growth, not only in the well-being of patients but also in the capabilities of oneself as practitioner (see Chapters 16, 29)

• the use of critical, creative conversations (Higgs 2006a) to make clinical decisions.

It is preferable to view clinical reasoning as a contextualized interactive phenomenon rather than a specific process. The practitioner responsible for making the decisions interacts both with the task and informational elements of decision making and with the human elements and interests of other participants in the decision making. Such interactions can be called critical creative conversations that involve interactions based on critical appraisal of circumstances and, where possible, critical interests in promoting emancipatory practice, and the creation and implementation of particularized, person-centred healthcare programmes (Higgs 2006a).

THE ADEQUACY OF DIFFERENT INTERPRETATIONS

There is no single model of clinical reasoning that adequately represents what clinical reasoning is in the context of different professions and different workplaces. The reason for this lies in several factors:

• the complex nature of the phenomenon of clinical reasoning and the consequent challenges of understanding, researching, assessing and measuring it

• the context-dependent nature of clinical decision making in action

• the inherent individuality of expertise

• the changing conceptions of quality and error in clinical reasoning

• the challenge to novices in developing clinical reasoning skills and to educators in facilitating this development.

THE NATURE OF CLINICAL REASONING AS A PHENOMENON

Consider the real world of clinical decision making. Orasanu & Connolly (1993) have described the characteristics of decision making in dynamic settings as follows:

• Problems are ill-structured and made ambiguous by the presence of incomplete dynamic information and multiple interacting goals.

• The decision-making environment is uncertain and may change while decisions are being made.

• Goals may be shifting, ill-defined or competing.

• Decision making occurs in the form of action–feedback loops, where actions result in effects and generate further information that decision makers have to react to and use in order to make further decisions.

• Decisions contain elements of time pressure, personal stress and highly significant outcomes for the participants.

• Multiple players act together, with different roles.

• Organizational goals and norms influence decision making.

To work within this practice world we need an approach to clinical reasoning that accommodates these complexities. Higgs and colleagues (2006, p. l) described a number of key characteristics of clinical reasoning as follows:

• Clinical reasoning as a solo process is a complex mostly invisible process that is often largely automatic and therefore not readily accessible to others in practice or research

• Clinical reasoning is linked with more visible behaviours such as recording diagnoses and treatment plans in patient histories and communicating treatment rationales in team meetings, case conferences and teaching novices

• Clinical reasoning and practice knowledge are mutually developmental; each relies on the other, gives meaning to the other in the achievement of practice and is the source of generation and development of the other

• Clinical reasoning can be implemented as a sole practitioner process or a group process

• Clinical reasoning may be understood as both cognitive and collaborative processes; however, in either case there is a growing imperative, linked to increasing demands for evidence-based practice and public accountability, to make reasoning more explicit

• As well as core reasoning abilities, language and interactive behaviours are required for understanding and developing practice knowledge and clinical reasoning

• Recent research has emphasised the importance of understanding clinical reasoning behaviours and effectiveness (including the communication of reasoning) in relation to contextual influences and chosen or required practice models

• Clinical reasoning requires a range of capabilities including cognitive, metacognitive, emotional, reflexive and social capabilities

• Clinical reasoning is, and for the purposes of quality assurance, should be, a reflexive process which involves practitioner(s) in critical self-reflection and ongoing development of their reasoning abilities, knowledge and communication (of reasoning) abilities.

DIFFERENT INTERPRETATIONS OF CLINICAL REASONING

In various chapters of this book a number of interpretations of clinical reasoning are discussed from the perspective of different disciplines, the history of clinical reasoning research, and models of practice within which clinical reasoning occurs. In Table 1.1 we present an overview of key models,strategies and interpretations of clinical reasoning. These have been divided into two groups: cognitive and interactive models. This division reflects three trends: changes in the focus of research and theoretical understandings of clinical reasoning (see Chapters 18, 19); changes in society and expectations of health care (see Chapter 2); and a major shift in emphasis (as outlined above) from the second to the third edition of this book.

Table 1.1 Models and interpretations of clinical reasoning (CR)

Expertise and clinical reasoning

In a review of clinical reasoning literature in medicine, Norman (2005) suggested that there may not be a single representation of clinical reasoning expertise or a single correct way to solve a problem. He noted that ‘the more one studies the clinical expert, the more one marvels at the complex and multidimensional components of knowledge and skill that she or he brings to bear on the problem, and the amazing adaptability she must possess to achieve the goal of effective care’ (p. 426).

Clinical reasoning and clinical practice expertise is a journey, an aspiration and a commitment to achieving the best practice that one can provide. Rather than being a point of arrival, complacency and lack of questioning by self or others, expertise requires both the capacity to recognize one’s limitations and practice capabilities and the ability to pursue professional development in a spirit of self-critique. And it is – or at least we should expect it to be – not only a self-referenced level of capability or mode of practice, but also a search for understanding of and realization of the standards and expectations set by the community being served and the profession and service organization being represented. Box 1.1 presents these characteristics and expectations of experts.

Tags: Clinical Reasoning in the Health Professions

Apr 20, 2017 | Posted by admin in GENERAL & FAMILY MEDICINE | Comments Off

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Clinical decision making and multiple problem spaces

UNDERSTANDING CLINICAL REASONING

CLINICAL REASONING AND METASKILLS

THE ADEQUACY OF DIFFERENT INTERPRETATIONS

THE NATURE OF CLINICAL REASONING AS A PHENOMENON

DIFFERENT INTERPRETATIONS OF CLINICAL REASONING

Expertise and clinical reasoning

a) General characteristics of experts (Glaser & Chi 1988)

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