Clinical Reasoning Cycle Workshop - Video Transcript
I’m Angela McKay and I co-ordinate the undergraduate program at Utas. Clinical reasoning is a mental cycle or model that we use in simulation, in order to facilitate students cognitive thinking around clinical episodes. As many times as we possibly can we facilitate clinical reasoning. The workshop today is really around sharing that with you. And how you can use that and facilitate clinical reasoning in our undergraduate students. The importance of that is - there is research that shows that 60% of our graduate nurses don’t have the clinical reasoning or critical thinking skills for safe patient care. That’s alarming. We know there’s lots of safety and quality agendas now that we do need our students to have the cognitive skills to be able to deal with the complexities of nursing. What our students often see from you is lots of action, and actions are skills. These tend to become task focused. But what they don’t see is the cognitive skills that you all have. They go on inside your mind every time you provide a patient care or a patient episode.
So, clinical reasoning is this mental model and framework to make explicit to students – what is actually going on, and what you are thinking of. It’s not new to professions like dieticians, or social work, or to paramedics, or to medicine, or to physios and IT’s. They teach clinical reasoning in their courses that actually underpins what they do. For nursing the University of New Castle received an ALTC grant which is a big Australia and New Zealand teaching grant, which was worth a lot of money – to develop models for nursing. So we could teach it. What we know about our students is that our good students have critical thinking abilities. Clinical reasoning comes from a critical thinking disposition. Our good students have critical thinking. We know what critical thinking looks like, but we don’t actually know how people learn that. So of our students enter the course with good critical thinking. Some of our students struggle with that concept all the way through. Without having medical models without critical reasoning we have to always wonder or assume that our students just pick it up.
As a hospital trained nurse, I’ll speak about myself. The way that I have developed critical reasoning is from pattern matching and multiple exposures and experiences to certain things. We all know that story of if someone rings the call bell at 3am in the morning. You better stand outside the door; they are going to have a heart attack! Does anyone know that one? How do we know that? That’s the kind of pattern matching thing – we have all had this experience before, I know what’s going to go on here! Or you only have to look at someone and straight away I’ve seen this before. Our students are not kind of there with that, so we need to be able to facilitate that kind of thinking. And especially our students who are struggling - as many times as possible.
So, first of all I’m going to get to set up a bit of a game. All it is, is for us to go on with a conversation around critical reasoning. But I want you to realise the students perspective from the game we are about to play. Those of you who have played it before – I need three groups basically. The minimum of seven in each group. There can be more; you can share a picture card. I’m going to actually give you a picture card, the object of the game is to put the pictures into a sequential line – face down on the table. The game rules are that you are not allowed to show your picture to each other. You have to work out what the sequence of events is by describing what’s in the pictures. You have got 10 minutes to do that. Those that have played the game before – I’m going to get you to be part of one of the groups to assist with the, you know how to do it. So if you could just help with the game and it will all come back to you once we hand them out. So if you could just form three groups.
How did you come up with your sequence of events? What strategies did you use? We relied on mercy. Good you relied on experience, your all experienced nurses in this room. Sorry, experienced clinicians in this room. I apologise, that’s wrong. So, you were reminiscing about things. What were you using the pictures for? You were looking for cues, so you were looking for the environment, and what else were you looking for in that picture? Sequence of events, recognising people by what they were wearing, looking at uniforms, environment, and equipment in the space. Wall colours, bed colours – trying to decide what spaces they are in and all that kind of thing. What might make it hard do you think to get the sequence down and – you know, you had to trust the information that people are giving you. It was all verbal, so you had to rely on listening. When we get verbal information – we have to have some sense of cognition that we can relate to. So if you were able to make some sort of sense based on your experience in the clinical environment, procedures in the clinical environment etc., so that’s the kind of skills that you were using. But you’re already drawing on your cognitive brain, your experiences – so you’ve got some cognitive brain action that’s going on there. For students, this is the game they play every day in clinical settings – so that if you’re talking to them, they may have no cognitive frame to draw on at all, it might be blank, like nothing comes to their mind. Your role is to constantly help them to put the big picture together.
Did anyone find this game boring, and demotivated? There’s always someone in a group that gets a bit frustrated with this game, the fact that it’s not goal orientated. You’ve been given no information; you’ve just been given this game to do. So, for some people it does make them feel a bit frustrated. I have seen some people in groups completely disengage and remove themselves from the game. For some students, they can get bored, demotivated and they don’t actually know the purpose of it. The other thing that makes the game challenging is – do you want to know what the right setting is. I’ll do what she’s telling me, but I don’t know if I’ve got it right. No confidence that you’ve got it right. The reason is that I’ve given you no context to the situation, the background or what is actually going on in those pictures. So then there’s no way you can actually get it right – Students need that type of assistance.
So, if I was to tell you the sequence – This is the first picture. What this is a clinical scenario that we run in a private hospital in Launceston with a patient in a recovery room. From that deterioration, the ambulance was called to be transferred from one campus to intensive care. Next transported down the corridor. Loaded up into the ambulance. Next, their arrival at ICU at the other campus. Then the patient actually has an MI. Then the ambulance is called again and then the ICH. But that, so that’s just really an example – as the person that holds the knowledge, needs to impart the information so the learner knows what is going on. So it’s just to demonstrate the way a student is – just seeing bits of the picture, as the supervisor we help to put it together. Clinical reasoning is the mental model that can help you facilitate piecing the pictures together, so they can see the big picture. So, in that game you all had a piece of the picture but nobody had the big picture, only I did. So we are just going to relate that to how students arrive when they are coming into hospital systems.
So, they need assistance to see that, our learners – as they synthesise bits of knowledge that you provide them, they start to put the big picture together. Usually once they have been guided they start to put the bits together themselves, it’s kind of just taking it a few times, spending the time to talk through things. They start to be able to match it. Without the big picture, they are basically just following you around. It’s not goal orientated, they get bored, they get demotivated and they base everything on assumptions. You know, they just make it up. Basing on assumptions also means is that they are taking your skills for granted. They think these processes just happen. Therefore, they might not seem very respectful to you and we talked about that being something that you really want them to do. So, they just think – oh yeah she’ll do it, and they just follow you around all day. As much as you put the big picture together, the more they will engage in the setting.
This is the clinical reasoning cycle that Tracey Levitt-Jones, and Kerry Hoffman, and I forget somebody, before I try to name them all. But there was a team at the University of Newcastle and this is based on Kerry Hoffman’s PhD and more thinking and reading about it all they put this mental model together. What they are trying to do is to make the reasoning explicit to students. We’ve got a teaching model that we can show a student – this is what expert nurses are doing and it’s based on observing expert clinicians and then it was just written up in this way. Is this a similar model, have you got more rules that they used in allied health? It’s a bit like critical thinking, clinical judgement and other terms like that. We assume that you pick it up and understand what it means. This is naming it up and making it clear for students – the process for cognitive processes that you do. Because otherwise they don’t see that. I’m just going to explain each phase of the model and related it to students. And that means that I’m using to talk about clinical reasoning - is what I see students do in simulation. So I’ll just give you some examples of what I know about students and mainly my experience around second year students. So the cycle has eight phases to it:
- Considering the patient
When you have a client that comes to you. What is the first thing you do? I guess if I was to say to everyone in this room – have a look at this picture, what is going on here? What can you name up? What would you say about this person? First impressions, collect impressions straight away, as soon as you see them, as soon as you lay eyes on them - you start to think about that. What else is going on? Someone is already in attendance so, yep, it’s probably pretty serious if there’s someone. Looks like he’s having the situation explained to him. He’s got a look on his face hasn’t he!? If I was to see – or the patient feels so dreadful he can’t actually be reassured at the moment. It’s probably something cardiac because he’s got all those leads on. So as a registered nurse, you could be walking past this cubical and you could be like – hmmm, something’s going on in there.
So, Talia – when you had a client your first visit through. But there are processes that go on straight way, your initial impression of someone. That’s the stuff students don’t get. Your probably go to greet your client, you’re probably looking at what there gait is etc. What sort of things do you pick up just from looking at a patient? Whether or not they are obviously malnourished, or over nourished, whatever the case maybe. There are some pretty standard things that you do straight away. Then you probably head off to look at notes or the information you’ve got from hand over. You place the context and background in relation to that patient pretty much straightaway. So you would say – you know, this guy in cubical one is looking pretty dreadful. Someone is already in attendance. It looks like its cardiac. So you straight away do that. I know from clinical simulations that the student nurses do.not.do.that. If I was to say to them – what’s going on here? They would go, ummmm – if I say place the context, background and situation they would really struggle. If they go into a simulation and there’s a patient that they are looking after with asthma and I go in to look at the end and debrief – I go what’s the situation? They go – his heart rates 100 and his blood pressure is 140 on 70. Alright, let’s go back a bit further. What did you get told at hand over? What were your impressions when you first walked in the room? So, then they start to put that, and if you think that they are not able to put that together. The rest of the clinical reasoning cycle is going to unravel pretty quickly. So, they need help in that. Basically you’re just saying out loud your first impressions to them. And that will help. Straight away they will go – oh right! Then click onto the next thing. So, Vanessa, you probably need to say that out loud what you’re doing when you’ve got a student with you. You know, really help them to gage the first impression, your helping to facilitate that part of the clinical reasoning cycle.
- Collecting cues
From you initial impression you usually, or you already have decided what cues you’re going to collect. So what further investigations you might do. Do you need to do the seven vital signs at this stage? Do you need an ECG? Do you need a questionnaire? Do you need to put a food monitoring, you know those kinds of things – what do you need to put in place to collect more information about this patient?
The students are pretty familiar with this whole, just look at a monitor and I can get information off that, I can get an ECG etc. They don’t see the cue collection in an interview and they are probably not very good about collecting cues about a lady on her frame walking towards them. They are probably not good like you Kim, at walking in to a home and you see a tablet dropped on the floor – and you start thinking: I wonder if they have had their medication today? Or how long it takes for the client to get to the door when you knock. You know, you start collecting cues from the minute you are there. You walk into a room and you start to do that. They are kind of like – I don’t know! Because these are the cognitive activities that you are doing. So your action – you walk into the room, pick up the tablet off the floor. They see that!
Cues in the clinical reasoning cycle are your objective data. So your objective data is something you can measure, and your subjective data is what the patient says is going on with them. It’s also – history, notes, pathology, x-rays things, like that, that you start to gather to figure out what is going on.
- Processing information
Processing information is when you have done your initial impression, so when processing you’ve done all your cues. Collect your cues together and you make sense of what’s relevant and what’s not, and what’s important and what else you need to consider and you cluster cues if you’re making an assessment about what’s going on. Generally in healthcare at the moment processing information is what we call metacognition. Cognition is thinking and metacognition is thinking about your thinking. So this processing information and the cues collected to come up with the problem. Just the fact that we’ve got lots of decision making into our role means that the processing of information has somewhere – maybe we’re not good at it. Or our new students coming through don’t have enough pattern matching or enough experience that they still need tools like on the charts to tell us when somebody’s in danger, or you know – the flags, lots of decision making guidelines are coming in. So it’s a skill that we obviously need more practise at and metacognition is something that you have to train your brain to do. It’s not something that just comes naturally. Actually putting all your data down and really considering what’s going on here is an important part of our role. And, of course a second year student is not really good at processing this information. The other thing they don’t do is collect broad enough cues. They just collect the obvious. But as experts we tend to collect a broader rang of cues, ask more questions and even if we’ve got someone who is having a respiratory issue we would probably still collect a blood sugar level and, you know, a few other things - for example. So as experts you draw broader and then process it.
So from processing information you come to the next stage of the clinical reasoning cycle – to identify the problems.
- Identify the problems
So problems can be a diagnosis if that’s the area that you work in. It can be just naming up the problem. So it could be – oh, this is linked to dehydration. Or this is high blood sugars, or this is linked to a higher pulse etc. So it’s either making a diagnosis or it’s naming the problems. Then it’s prioritising the most pressing issue. So floored under load, floored overload – you’ve got to name it something. If you don’t name it up, then you fail to take action, so it’s an important part of the process. The students in SIM always argue with me and say – I’m not allowed to name up the problem. I always say – who said that? Where does that actually come from? Well, we are not allowed to make a diagnosis. No you’re not allowed to make a diagnosis, like a medical diagnosis, but you are allowed to make nursing diagnoses. You are allowed to name up the problem and you’re allowed to have a hunch. You know – I think this is what’s going on. How do you communicate it otherwise? So, you know, it’s an important step to get to. I think, you need to move to that step.
- Establishing goals for the patient
So, a lot of the nursing care plans are goal orientated. Often goals in health care are around the patients goals of care. Establishing goals, Vanessa, is it something that you do for your patient? Yep, absolutely. Yeah – so that’s pretty straightforward.
- Take action
So then taking action is your interventions. What to put in place to improve for your patient and then:
- Evaluate Outcomes
These parts of the cycle are where we get to quite easily. The students are very good at evaluating whether this is working or not. They’re actually quite good at taking these steps, even though sometimes they know they need to do something – but their uncertainty makes it look really messy. Then they don’t go back to saying – I’m going to do this because of the cue is here. So they don’t rationalise it back to the cue. So they have a bit of a problem with that. Sometimes they will just abandon their knowledge and go on gut feeling. Their intuition, because they know they need to do something. But when you get them to recall why they did something they are good at recalling it. Good at recalling their knowledge. So that takes us to step 7.
- Reflection on process and new learning
Final stage - Reflection with knowledge is important for learning and allows the students to process their experience and they can explore their understanding so we do use critical reasoning in our undergraduate program to facilitate reflection and they reflect and go all through the cycle to reflect on a clinical simulation. So we put the big picture together. They also love SIM because it helps them to think about the big picture. Which is, you know, what they are doing. So clinical reasoning can be used in your work place and when your supervisor has in students to help, you know – debrief them at the end of the day, help them put the big picture together. It’s just the steps of the cycle that you need to remember and the language that goes with it.
The reasons for the school of nursing adopting the university model of clinical reasoning was because our students go into really complex health care settings. It’s getting more complex, even patients in a community are complex. It’s really complex now and I just reflect on my time as a student and I was a hospital trained student. I would have a four bed ward. Two of the patients were two day pre-op. They were sitting around in their dressing gowns reading the paper, looking immaculate because they were in to have bloods and an x-ray and to fast – we couldn’t let them fast at home, we couldn’t trust them. So, not everyone was acute, you actually had a mix. But now our students are faced with patients who are immediately post-op and they have never even met them before they arrive. They’re discharged from the in suite straight to the ward. So, they don’t actually know a situation until they are there. We don’t know our patients as well as what we used to be able to get to know them pre-op.
Also, because of the complexity our students are required to engage in that higher order cognition immediately with the acuteness. And that’s a process that prevents adverse events. They need vigilance, they need to be able to walk up and take it all in. There’s also a gap between theory and practise because of the little time our students now spend in practise. Its 20 years since the, it’s actually over 20 years, about 25 years now since the apprenticeship model of healthcare students. There’s still, though, very theoretical and not a lot of hands on. So what we think is that the clinical reasoning cycle adds a bit of a thread to have conversation around what goes on between theory and practise.
There are a few definitions of clinical reasoning – bringing home that it is a cognitive activity and our students don’t see the cognitive activity. We are trying to make it really explicit to them. It’s a thinking process that manifests into action. Without being offered the opportunity to talk through the clinical reasoning it’s gone – and they only ever see the action. Therefore, nursing can be seen to be very task orientated. They just see the tasks and they want the skills, and actually a lot of a nurse’s skill work is not all about the thinking mode. So, clinical reasoning is about the problems that - the way a clinician thinks about problems that they deal with in practise. So we can relate to the work that you actually do every day and how it can help students to increase their theory practise.
The research comes from a PhD by Kerry Hoffman and she based the clinical reasoning on what experts and experienced nurses do automatically and instinctively. And every clinician engages multiple times in clinical reasoning in a patient care episode. And there is some research out there that says a medical nurse engages in probably 50 significant clinical reasoning cycles per shift. Someone in a really acute area, a professionally acute area can end up clinically reasoning every 30 seconds. The higher the acute, the higher the cycles you are actually going through. So, it’s a model for students. There are links to poor clinical reasoning skills to patient out costs.
The reason that the university has taken on the clinical reasoning model is that we do want to enhance our nurse’s critical reasoning skills. We also want to build a common language to be able to use with students. Being able to use the language of the clinical reasoning cycle we can all be on the same page and the students get what we are trying to talk about. Students start clinical reasoning in first year – have excises to do, they have assessments on it. Theory around it - A lot of their assessment tasks are now critical reasoning based. We also think it’s a language that clinical facilitators can use to assist their learning experiences.
How we use clinical reasoning as well, and we think preceptorship can use it is that it can be a structured line of questioning that the students understand. So you can assess a student’s knowledge and understanding with it. You can work out whether they are actually thinking, or just making assumptions or just taking things for granted. It can also provide participatory guidance for students. For example – I’ll use Vanessa’s example. Before you actually see a client and you’ve got your client coming you could say. I’ve got this client, this is the reason he’s taking care – so when we enter the room, I’m just going to take a first impression. This is what I’m looking for, this is why I do it, and these are the things I’m going to just do initially. Then I do need to collect some information from them, so I’m going to fill out this questionnaire, or I’m going to do this set of obs. Or do this assessment. I’m going to ask the patient these kinds of questions. Then you can work into, then we are just going to analyse then what’s going on with this patient. We will see what the problem is. The likely problems are, you can take a hunch at that point – because you probably are making an assumption. The likely problems are, so the interventions we are going to do, and how we are going to evaluate the situation is this – and we’ll see them again in a couple of weeks. Do you have any questions about that? So you can be anticipating – you’ve got a patient coming in. Emergency department, chest pains, same thing – how to look at the patient, see how they are. What I’m looking for is their colour, are they sweaty, this ideal – work through the cycle. So, are you actually painting the picture first? To help them out.
Then you can also use it as a debriefing for a critical incident to make sure that they learn from it. So, for example you have just done that lovely nice talk about this patient coming in with chest pain and it’s completely unexpected. The patient gets in the door and crashes immediately, everyone is on top of them, there are catheters, there’s tubes and everything going on. Full resuscitation. Afterwards you can go – ah, ok, we thought it was this, but actually this was the situation. These are the cues that it was that. This was the problem he ended up with; these are the interventions that we had to do. Talk them through in that way. And talk through if you’re assessing a student. If you’ve got real concerns about a student, you can use that language to say – ok, so we just went in and we were looking after this mother, you know, what do you think the situation was? Talk it through. And that’s my last slide – any questions regarding clinical reasoning?
Question : I was just thinking that it’s not really easy to teach. You can’t teach lateral thinking. It’s something that does come eventually and it is not an a,b,c thing that you can say – do this, this and this and it just comes. You might have very junior learners and then you might have older learners as well – so completely differently.
Answer: I’m suggesting that you just facilitate the thinking. Because they will construct the knowledge around that. The amount of times you can facilitate this long line of thinking is really where you want to go with it. Because, you’re right, you can’t just teach it. You have to actually construct it through a structured process that’s all you’re actually offering them. For them to be able to make sense of what’s going on. Basically we are just facilitating – whether they learn it or not. There will be students who probably will still struggle with it. But what we are trying to do is facilitate the thinking as many times as we can. To just keep developing it, so by the time they are a graduate, they have got the concept.
Question: In the package there was a section on clinical reasoning errors. How much to do you talk about that with students?
Answer: We do in third year. Third year we move to that anchoring and that. We also do an exercise with our third years where we give them a hand over and we talk about – right, we have got this patient and he’s a 20 year old. He’s obviously drug seeking. So we build up all of this stuff in the hand over and then the students go off to manage this patient and the actual attitudes, so what, they are anchored on that – this kind of patient is drug seeking, has a drug history, and so on. Then it actually affects their clinical reasoning. We do have a couple of exercises like that and around those anchoring issues. There in that book because it’s kind of an advanced thing, so as they go through in first year – we don’t really expect them to get through to the collecting cues part of the clinical reasoning cycle and starting to name out problems. Then in second year we expect them to go right around to evaluation, right around. In third year we expect them to understand some of the things that affect their clinical reasoning.
Question: Where did you say you got up to in second year?
Answer: End of second year they are doing the full cycle. The first simulation scenario that they have around clinical reasoning – they are all over the place. It’s really fascinating, we have a patient come in who is dehydrated and he has an increased heart rate, low blood pressure, he has a bowl obstruction and he’s got a catheter in and a basic gastro-tube. They don’t even collect the broad cues – they don’t go to the catheter and go, oooh there’s only 20mls in there. Then go to the gastric tube and go ohhh look how much is here? There’s 500mls. So it’s, and you know, that’s the first simulation scenario they have and that generates a discussion. Oh, your cue collection is here for this patient. So they are actually quite competent scenarios that they do in second year. By the end of second year they are in there snapping through pretty quick.