Fundamentals of Nursing and Midwifery 2e

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

judgement and choosing an action to be taken. Clinicians who wish to develop the clinical reasoning skills essential to thoughtful practice will find it helpful when posed with a clinical challenge to work methodically through the set of five types of considerations shown in Figure 14-3. These relate to the purpose of the thinking (the question), the adequacy of your knowledge about the issue, the potential problems, where helpful resources may be found, and finally making a judgement and deciding on a course of action. Focus on the question about the particular issue The first step in clinical reasoning is to focus on the ques- tion in order to identify the purpose or goal of your thinking. This helps to discipline your thinking by directing all your thoughts towards the goal. For example, the purpose of clin- ical reasoning might be to make a judgement about a particular person or situation or to make a decision about how best to intervene. Consider what knowledge you have about the issue At the outset of clinical reasoning, it is important for you to judge whether the knowledge you have is accurate, com- plete and relevant. If you are reasoning with false information or with limited data, it will be impossible to draw a sound conclusion. You also need to be sure that you understand all of the details relevant to the issue. What is at stake? How much time do you have to make a decision? How much scope is there for error? Identify and address potential problems As you become skilled in clinical reasoning, you will learn to ‘flag’ and remedy the pitfalls to sound reasoning. Common problems include working with untested or faulty assumptions, accepting an unproven claim or line of argu- ment, allowing bias to colour your thinking and applying illogical reasoning (that is, making a generalisation on the basis of a single experience or case, or allowing emotion to overrule reason). The more familiar you are with these common impediments to clinical reasoning, and the more self-aware you are, the easier it will be to detect them in your own thinking. Seek appropriate resources to assist you Wise professionals are good reflectors and are quick to recognise their limitations and to seek help in remedying

problems often overlap in any given situation, so the process may occur in concurrent cycles. Now that you have completed the explanation of thought- ful practice, you can concentrate on learning the skills required for clinical reasoning. Refer back to Figure 14-1 to refresh your understanding of the relationship between the components of clinical reasoning in preparation for the next section of this chapter, which describes how to develop and apply your clinical reasoning skills. APPLYING CLINICAL REASONING SKILLS Throughout this text you have been participating in exer- cises that are preparing you for thoughtful practice by building your skills in clinical reasoning and reflection. You have encountered short critical-thinking exercises at the end of each chapter, focusing on what you were learning at the time. These exercises required you to think in a systematic, focused way to answer a question about a particular situa- tion. These exercises have been preparing you for clinical reasoning by developing your ability to analyse a situation and apply the knowledge you have acquired. In addition, you have encountered reflective cues that require you to draw on your own experiences and examine your own thoughts and feelings relating to an encounter with a patient. These reflective cues have been developing your ability to look within and understand how reflection can help you to grow professionally and to improve your practice. This chapter now consolidates your learning in clinical reasoning through a demonstration of how to apply a clinical reasoning framework to a particular clinical situation that has greater scope than the small-scale exercises you have com- pleted so far. In real life, each particular clinical situation will present its own challenges, so it will be helpful for you to develop a method of thinking through a problem in order to arrive at a clinical judgement and decide on a course of action. Although there are a number of methods available, the method shown in Figure 14-3 is uncomplicated and is particularly suitable for the developing nurse or midwife. Developing the method of clinical reasoning Clinical reasoning is the process of analysing a situation, deciding on possible alternative reasons for it, making a

Consider what knowledge you have about the issue

Identify and address potential problems

Seek approptiate resources to assist you

Make clinical decisions and judgements

Focus on the question about a particular issue

Figure 14-3 Clinical reasoning framework