Fundamentals of Nursing and Midwifery 2e

255 Chapter 14 Thoughtful practice: Clinical reasoning, clinical judgement, actions and the process of care

Personal attributes All people think or reason as they go about their daily lives. Reasoning has a logical or cognitive (thinking) component as well as an emotional or affective (feeling) component, and is affected by the personal attributes of the thinker (Hoffman, Duffield & Donoghue, 2004). Clinical reasoning is also affected by the beliefs and values held by the clini- cian (da Silva et al., 2010). The personal attributes that affect clinical reasoning are summarised in Box 14-1 and explained in the following section. Willingness to learn Reasoning ‘starts with an inquiring mind, proceeds with per- sistent thinking, and results in multiple possible answers to a recognised problem’ (Fowler, 1998, p. 184). Chapter 13 dis- cusses how reflection is used to help us to learn from practice. While all clinicians need to learn from reflection and experi- ence, the ability to reason well begins with the building of the individual clinician’s knowledge base. The extensive know- ledge base that is required for practice is discussed previously (Chapters 1, 9 and 13). However, clinicians not only need to recall facts, they also need to recognise the cues that inform them of a problem. Cues are the pieces of data that the clini- cian collects through observation, reading records and talking to patients and others. Cue acquisition is when the clinician recognises the importance of these pieces of data and collects them (Levett-Jones et al., 2010). For this reason, clinical rea- soning is taught in most undergraduate programs, often using case studies or scenarios. This learning is consolidated in clin- ical placements. You need to learn from each clinical encounter so that you can relate the significance of the cues that you have collected to the knowledge that you have been building, and apply these cues to new and often complex

situations (Alfaro-LeFevre, 2012). This then adds further to your knowledge base, growing it exponentially, helping you to build patterns and providing templates for problem solving in the future. This in turns builds better reasoning processes. As learners we are all different, but we are all alike in our need to make learning an active and lifelong exercise, and in the need to base our reasoning processes on learnt material based on current, evidence-based practice and the associated literature. This learning is then consolidated and shaped by reflection. Willingness to develop self-awareness In Chapter 13, the seminal place of self-awareness in thoughtful practice is outlined. What the concept of health means to each individual influences their expectations and desires in relation to healthcare. These expectations and desires in turn influence the reasoning process, through the beliefs and values that the person doing the reasoning brings to the reasoning process. For this reason, clinicians must develop great self-awareness of their own beliefs and value systems, and an understanding of how their prejudices and assumptions can affect their decisions. This may occur through reflection, which can help to expose any biases or preconceptions. Prejudice literally means ‘pre-judging’ or ‘judging in advance’, which is a process that destroys rea- soning by forming premature conclusions that may be incorrect or not in the person’s best interests. An example of this occurs when a clinician is influenced by preconceptions of what older people should be like. This can affect the cues collected, the judgements made and the behaviour of the cli- nician through the actions taken (McCarthy, 2003). We can identify and deal with our own prejudices through reflection and examination of our own thought processes (Paul, 1995). Self-awareness enables us to clarify our own biases, inclinations, strengths and limitations, and thus helps us to acknowledge when our thinking may be influenced by our emotions or by self-interest. Sound clini- cal reasoning must accommodate the values and beliefs of both parties in the relationship because person-centred care adopts a shared model, with the patient truly involved in the choice of care options (Tanner, 2006). We need to enable reasoning that is not based on erroneous assumptions about the person for whom we are caring. As Alfaro-LeFevre (2012) states, clinical reasoning must overcome the powerful influences of reasoning that is curious and inquisitive, and that seeks reasons, explanations and meanings for the problem that is the subject of the reasoning. Freedom from prejudice enables the person doing the reasoning to seek new informa- tion to broaden understanding, and removes constraints to reasoning. Confronting prejudice leads to sensitivity to diver- sity and an appreciation of human differences in terms of values, culture and personality. When reasoning is also under- taken with the engagement of the patient, the reasoning is person centred. Willingness to know the person (engagement) The degree of reasoning that the clinician brings to the processes of care is also influenced by the degree of

BOX 14-1 Personal attributes that affect clinical reasoning

Willingness to learn • Problem solving • Reflection Willingness to develop self-awareness • Beliefs and values • Prejudices and assumptions

Willingness to know the person (engagement) • Full or partial engagement, disengagement Willingness to put all the pieces together • Motivation • Moral agency Willingness to make a decision • Confidence

• Support roles and responsibilities Responsiveness to the environment • Culture and power • Behaviour