Dissertations / Theses on the topic 'Clinical decision making;reasoning;judgement'

Clinical decision-making (CDM) research has focused on diagnostic reasoning, CDM models, factors influencing CDM and the development of expertise. The research approaches used, including phenomenology, have not addressed the question of how CDM is perceived and approached by nurses. This study describes perceptions of CDM in relation to patients in pain using a phenomenographic methodology. At semi-structured interviews, participants were asked to recall their responses to a situation involving a patient in pain. The responses fell into four categories: (1) the effect of the clinical environment; (2) the role of other health professionals; (3) the place of the patient; and (4) the role of experience. Examples of differences in perceptions that were likely to impact on the nurses� approach to CDM include: the ongoing effects of time and workload demands on CDM; nurses are initially dependent but were eventually able to make decisions autonomously; the patient who may be peripheral or central to CDM; and the nurses� move from the use of theoretical principles to experiential knowledge as reflection-on-practice is employed. Perceptions in all categories are strongly implicated in the nurses� sense of confidence and independence. Implications for nursing practice and nursing education suggested by the findings relate to the number of areas in which graduates work in the first year of practice, the size of new graduate workloads, graduate transition programs, the place of reflection-on-practice and undergraduate (UG) program clinical experience patterns. Among issues for further research arising from the study are: replication of the study; detailed examination of the development of CDM in the first year of nursing practice and during UG nursing education programs; the role of other health professionals in the development of CDM behaviour; the links between CDM and clinical knowledge development; and the type of clinical environments that foster confidence and independence. A conclusion of the study is that the way CDM is approached is influenced by the amount, quality, relevancy and recency of clinical experience. In this study, phenomenography was shown to be an appropriate approach to the description of nurses� perceptions of CDM in relation to patients in pain. In addition, nurses� changing perceptions over two years and the subsequent effect on CDM behaviour were described.

The British government currently requires mental health services to be targeted at the most needy (Department of Health, 1999). For occupational therapy services, where service demand far exceeds service availability, skill in referral prioritisation is essential. The studies in this thesis describe how experienced occupational therapists’ referral prioritisation policies were used to successfully educate novices. 40 British occupational therapists’ referral prioritisation policies were modelled using judgement analysis. Individuals’ prioritisation decisions were regressed onto 90 referral scenarios to statistically model how referral information had been used. It was found that the reason for referral, history of violence and diagnosis were most important. The occupational therapists’ capacity for self-insight into their policies was also examined by comparing statistically modelled policies derived from their behaviour with their subjective view of their cue use. Self-insight was found to be moderate (mean r = 0.61). A Ward’s cluster analysis was used on the statistically modelled policies to identify if subgroups of therapists had differing referral prioritisation policies. Four clusters were found. They differed according to several factors including the percentage of role dedicated to specialist occupational therapy rather than generic work. The policies that led to more of an occupational therapy role were found to give particular importance to the reason for referral and the client’s diagnosis. The occupational therapy professional body supports this latter method of working as it has recommended that occupational therapists should use their specialist skills to ensure clients’ needs are met effectively. Therefore the policies that focussed on clients’ occupational functioning were used to train the novices. Thirty-seven students were asked to prioritise a set of referrals before and after being shown graphical and descriptive representations of the policies. Students gained statistically significant improvements in prioritisation. Students’ pre-training policies were found to be those of generic therapists; a method of working that has been found to be leading to reduced work satisfaction and burnout (Craik et al.1998b). The training is therefore needed to ensure undergraduate occupational therapy students develop effective referral prioritisation skills. This will help to ensure that clients’ needs are met most effectively and work stress is reduced.

Although clinical reasoning is both broad and complex, the term “clinical reasoning” is contested and multiple definitions have been mooted within different contexts. In its simplest form, clinical reasoning is regarded as a “decision-making” process. Other definitions outline it in terms of a complex cognitive process, posited within multiple contextual factors. Traditionally, clinical reasoning models have been based upon cognitive theories. More recently, interpretive theories have been applied. Despite extensive research over the past four decades, no consensus on how clinical reasoning actually occurs has been achieved. Accurate clinical reasoning is vital to patient safety. Its importance as an essential clinical competence for healthcare professionals is well established. Indeed, it is the crux of a clinician’s work. Frequently, Foundation doctors are the first to review acutely unwell patients. During out-of-hours shifts senior help can be scant and Foundation doctors may have to rely on their own initial clinical reasoning to manage acutely unwell patients. This PhD explores clinical reasoning development in the transition phase between final year medical student and Foundation doctor (5MB-FY1 transition) in relation to acutely unwell patients. It follows a cohort of final year medical students from a single UK university on their clinical reasoning journeys as they transition into Foundation doctors, focusing on the role of the simulated healthcare setting and the workplace. The principle research question for this PhD was how does clinical reasoning develop across the transition phase between final year of medical school and Foundation year one? Within this overarching research question, the following sub-questions were posed: What do participants understand by the term clinical reasoning? What types of clinical reasoning experiences do participants narrate? How do participants clinically reason for acutely unwell patients? Which factors do participants perceive as being facilitating and hindering to their clinical reasoning? How do participants’ clinical reasoning processes develop across the 5MB-FY1 transition phase? This PhD uses multiple methodologies derived from interpretive approaches in innovative ways to tap into clinical reasoning processes and its development across four data collection points: T1: group and individual interviews; T2: Ward Simulation Exercise observations and stimulated recall interviews; T3: workplace observations and stimulated recall interviews; T4: final interviews. Data were collected from T1/T2 and T3/T4 during the final year of medical school and Foundation year one respectively. Primary thematic analyses were carried out cross-sectionally and longitudinally in terms of what participants said and how they said it. Secondary narrative analyses were undertaken of participants’ Personal Incident Narratives. By taking an interpretive approach, the complexities of clinical reasoning processes, both in terms of internal cognition and external socio-cultural influences were illuminated, drawing upon clinical reasoning, complexity and situated learning theories. The key findings of this PhD were that participants conceptualised clinical reasoning as a “decision-making” and “thinking” process, leading to a clinical judgement for patient care; participants narratives aided understanding of clinical reasoning process and factors which facilitated and hindered them; participants used experiential knowledge and protocols to clinically reason for diagnosis, investigation, management and prioritisation; participants retained flexibility and contextual variability in the processes of making their clinical judgements; multiple factors facilitated and hindered the equilibrium of clinical judgement processes; and clinical reasoning development is dependent upon a complex interplay of individual, interpersonal and systemic factors which are deeply embedded in social-cultural theory. This study has multiple strengths and original features such the high participant retention rate throughout the longitudinal study, the exploration of the 5MB-FY1 transition, contemporaneous observations of clinical interactions with patients, the exploration of the out-of-hour setting contemporaneously and the multiple methods of data collection used in innovative ways. This PhD develops the published literature further in these domains. However, its challenges were predominantly ethical, such as lack of patient capacity to consent in the workplace.

För att kunna ge vård av säker och god kvalitet krävs att sjuksköterskor har kunskap inom många områden, eftersom de har ansvar för såväl bedömning, planering och genomförande, som utvärdering och dokumentation av omvårdnadsarbetet. Ett av flera ansvarsområden för sjuksköterskor i deras dagliga arbete är beslutsfattande om insättning och skötsel av perifera venkatetrar (PVK). En PVK är en tunn plastkateter som sätts in i ett blodkärl via en kanyl. PVK används vid intravenös behandling med till exempel antibiotika och andra läkemedel, blodkomponenter eller näringslösningar. En stor andel av alla patienter inom hälsooch sjukvård kommer någon gång i kontakt med en PVK och riskerar då också att utsättas för komplikationer. En vanlig komplikation i samband med PVK är tromboflebit. Tromboflebit förekommer i olika svårighetsgrader och innebär att inflammation har uppstått i blodkärlet i kombination med samtidig blodpropp. Symtom som kan uppstå är rodnad, svullnad, smärta, hårdhet i kärlet och varig infektion. Det finns kliniska riktlinjer om PVK framtagna både på nationell och på lokal nivå som fungerar som ett stöd i beslutsfattandet. Tidigare forskning har visat att kliniskt verksamma ibland inte följer riktlinjer. Anledningar till att inte riktlinjer följs kan till exempel vara att de kliniskt verksamma inte håller med om det som rekommenderas, inte känner till rekommendationerna, inte har tid eller möjlighet att påverka de beslut som fattas eller att det finns individuella faktorer att ta hänsyn till för den enskilda patienten. 52 Frågan kan ställas om sjuksköterskor använder sig av kliniska riktlinjer i sitt dagliga arbete eller om det är andra faktorer och aspekter som har betydelse och påverkar beslutsfattandet. Denna licentiatavhandling syftade till att beskriva sjuksköterskors kliniska beslutsfattande genom att fokusera på deras följsamhet till riktlinjer och beslutsresonemang om PVK. Två studier har genomförts inom ramen för denna licentiatavhandling. Studie I undersökte i vilken utsträckning sjuksköterskor följer nationella och lokala riktlinjer om PVK. PVKns placering och storlek, tiden som PVKn varit placerad i blodkärlet, dokumentation vid PVKns förband samt om det fanns tecken på tromboflebit vid PVKn var variabler som undersöktes i relation till de rekommendationer som fanns. Utifrån två protokoll samlades strukturerad data in och analyserades. Totalt 343 PVK ingick i analysen. I studie II undersöktes de tecken och påverkande faktorer som har betydelse när sjuksköterskor fattar beslut om skötsel av PVK. I studien observerades 43 sjuksköterskor i sitt dagliga arbete. Sjuksköterskorna intervjuades också dels om PVK-besluten som de fattade under observationerna, dels om deras beslutsfattande om PVK-skötsel i allmänhet. Studie I visade att sjuksköterskor delvis följer riktlinjer. Det fanns skillnader mellan de vårdavdelningar som hade nationella riktlinjer och de som hade lokala riktlinjer, i hur de olika avdelningarna valde placering, storlek och dokumenterade vid PVKns förband. PVKn hade suttit längre tid än rekommenderat i varierande utsträckning. Andelen tromboflebiter var låg (7.0%) och tromboflebiterna var milda. Det tyder på att sjuksköterskor är noga med att ta bort PVK vid tecken på komplikationer. Studie II visade att sjuksköterskor i sitt kliniska resonemang om PVK-skötsel tar hänsyn till den individuella patientsituationen, sjuksköterskans arbetssituation och erfarenhet av PVK-skötsel. Det framkom även att sjuksköterskor balanserar mellan att undvika eller minimera obehag och smärta för patienten och samtidigt förebygga komplikationer från PVKn. Resultaten från denna licentiatavhandling kan få betydelse för undervisning av sjuksköterskestudenter och även när kliniska riktlinjer ska införas på vårdavdelningar.
Every working shift nurses make several decisions, including decisions about management of peripheral venous catheters (PVC). Peripheral catheterisation is a common procedure, which affects numerous patients in health care today. PVC are for example used for intravenous infusions with antibiotics, nutrients and blood components. Having PVC in situ may lead to complications such as thrombophlebitis. Clinical guidelines have been developed within the area to assist nurses in their decision-making, but clinical guidelines are not always adhered to. There are several reasons why clinicians do not always adhere to clinical guidelines, although such adherence may lead to fewer complications. Choices for decisions regarding PVC management have been investigated in previous studies, but not in a naturalistic setting. The overall aim of this licentiate thesis was to describe nurses’ clinical decision-making through focusing on their adherence to clinical guidelines and their clinical reasoning concerning decisions of PVC. Two studies have been conducted and data were collected during a six-month period, from December 2004 to June 2005. Study I investigated nurses’ adherence to national and local PVC guidelines by focusing on time in situ, site, size and documentation at the dressing. The thrombophlebitis frequency associated with PVC in situ was also investigated. Structured observations through two protocols were carried out and data about 343 PVC were analysed. Study II investigated nurses’ clinical reasoning regarding PVC management and cues and factors of importance in the decision10 making process were analysed. Nurses were observed in their daily work with focus on PVC management. They were interviewed both about the PVC decisions made in the observed situations and about factors influencing their reasoning regarding PVC management in general. The observations facilitated the interviews. Transcribed interview texts were analysed with content analysis. The results in study I showed that thrombophlebitis frequency was 7.0% and the nurses seemed to replace or remove PVC before any severe complications arose in accordance with clinical guidelines. Nurses partly adhered to national and local guidelines concerning site, size, documentation at the dressing and time in situ. Differences in guideline adherence were observed for wards with local or national guidelines, as well as for wards with different specialities. The results indicate that local guidelines may have an impact on guideline adherence but these results need further exploration. Analysis of interview texts in study II resulted in a category system with three main categories describing cues and factors of importance in the nurses’ clinical reasoning about PVC: the individual patient situation, the nurse’s work situation, and experience of PVC management. An overall theme was also revealed in the interview texts and the nurses balance in their clinical reasoning between avoiding or minimizing discomfort and pain for the patient and preventing complications from the PVC. The results from this licentiate thesis have implications for the education of nurses as well as during implementation of clinical guidelines.

Doctor of Philosophy
The aim of the research presented in this thesis was to come to a deeper understanding of clinical decision making from within the interpretive paradigm. The project draws on ideas from a number of schools of thought which have the common emphasis that the interpretive use of language is at the core of all human activity. This research project studied settings where health professionals and medical students engage in clinical decision making in groups. Settings included medical students participating in problem-based learning tutorials and a team of health professionals working in a multidisciplinary clinic. An underlying assumption of this project was that in such group settings, where health professionals are required to articulate their clinical reasoning for each other, the individuals involved are likely to have insights that could reveal the nature of clinical decision making. Another important assumption of this research is that human activities, such as clinical reasoning, take place in cultural contexts, are mediated by language and other symbol systems, and can be best understood when investigated in their historical development. Data were gathered by interviews of medical students and health professionals working in the two settings, and by non-participant observation. Data analysis and interpretation revealed that clinical decision making is primarily a social and linguistic skill, acquired by participating in communities of practice called health professions. These communities of practice have their own subculture including the language game called clinical decision making which includes an interpretive repertoire of specific language tools and skills. New participants to the profession must come to embody these skills under the guidance of more capable members of the profession, and do so by working through many cases. The interpretive repertoire that health professionals need to master includes skills with words, categories, metaphors, heuristics, narratives, rituals, rhetoric, and hermeneutics. All these skills need to be coordinated, both in constructing a diagnosis and management plan and in communicating clinical decisions to other people, in a manner that can be judged as intelligible, legitimate, persuasive, and carrying the moral authority for subsequent action.

This qualitative study describes how physical therapist experts in musculoskeletal disorders evaluate and interpret imaging studies and how they employ imaging in clinical decision-making. The informants are physical therapists who are certified orthopedic clinical specialists (OCS) and/or fellows of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). The study employed web conferencing to display patient cases, record screen-capture videos, and to conduct interviews. Informants were observed and their activity video-captured as they evaluated imaging studies and, afterwards, interviews were employed to explore the processes they utilized to evaluate and interpret the images and to discuss imaging-related clinical decision-making, including possible functional consequences of changes seen in the images, contraindications to treatment, and indications for referral. The interviews were transcribed and analyzed in the tradition of grounded theory. This study found that the informants’ evaluation of imaging studies was contextual and non-systematic, guided by the clinical presentation. The informants used imaging studies to provide a deeper understanding of clinical findings and widen perspectives, arriving at clinical decisions through the synthesis of imaging, clinical findings, and didactic knowledge. They tended to look for imaging evidence of interference with normal motion, rather than evidence of pathology. Overall, the informants expressed conservative views on the use of imaging, noting they would rather use clinical findings and treatment response than imaging findings as a basis for referral to other health care professionals. Using imaging studies to support clinical decision-making can provide physical therapists a wider perspective when planning treatment interventions. By showing physical therapists’ approach to interpreting imaging studies and how this relates to their clinical decision-making, the findings of this study could contribute to discussions of the place of imaging in physical therapist practice, as well as help set objectives for imaging curricula in professional-level and continuing education.

Thesis advisor: Dorothy A. Jones
Thesis advisor: Pamela J. Grace
The purpose of the study was to explore the relationship between multiple variables within a model of critical thinking and moral reasoning that support and refine the elements that significantly correlate with accuracy and clinical decision-making. Background: Research to date has identified multiple factors that are integral to clinical decision-making. The interplay among suggested elements within the decision making process particular to the nurse, the patient, and the environment remain unknown. Determining the clinical usefulness and predictive capacity of an integrated ethically driven environmental model of decision making (IEDEM-CD) in emergency settings in facilitating accuracy in problem identification is critical to initial interventions and safe, cost effective, quality patient care outcomes. Extending the literature of accuracy and clinical decision making can inform utilization, determination of staffing ratios, and the development of evidence driven care models. Methodology: The study used a quantitative descriptive correlational design to examine the relationships between multiple variables within the IEDEM-CD model. A purposive sample of emergency nurses was recruited to participate in the study resulting in a sample size of 200, calculated to yield a power of 0.80, significance of .05, and a moderate effect size. The dependent variable, accuracy in clinical decision-making, was measured by scores on clinical vignettes. The independent variables of moral reasoning, perceived environment of care, age, gender, certification in emergency nursing, educational level, and years of experience in emergency nursing, were measures by the Defining Issues Test, version 2, the Revised Professional Practice Environment scale, and a demographic survey. These instruments were identified to test and refine the elements within the IEDEM-CD model. Data collection occurred via internet survey over a one month period. Rest's Defining Issues Test, version 2 (DIT-2), the Revised Professional Practice Environment tool (RPPE), clinical vignettes as well as a demographic survey were made available as an internet survey package using Qualtrics TM. Data from each participant was scored and entered into a PASW database. The analysis plan included bivariate correlation analysis using Pearson's product-moment correlation coefficients followed by chi square and multiple linear regression analysis. Findings: The elements as identified in the IEDEM-CD model supported moral reasoning and environment of care as factors significantly affecting accuracy in decision-making. Findings reported that in complex clinical situations, higher levels of moral reasoning significantly affected accuracy in problem identification. Attributes of the environment of care including teamwork, communication about patients, and control over practice also significantly affected nurses' critical cue recognition and selection of appropriate interventions. Study results supported the conceptualization of the IEDEM-CD model and its usefulness as a framework for predicting clinical decision making accuracy for emergency nurses in practice, with further implications in education, research and policy
Thesis (PhD) — Boston College, 2011
Submitted to: Boston College. Connell School of Nursing
Discipline: Nursing

The introduction of legislation governing the management of mental illness in Queensland led to complaints from paramedics and their industrial association to the Commissioner of the Queensland Ambulance Service regarding the inadequacy of education and training to fulfil their new practice obligations. The industrial association asserted that their members were ill-prepared, insufficiently skilled, and unsupported professionally to make clinical judgements and decisions about mental illness in the pre-hospital emergency care setting. Furthermore, they raised concerns that their members were at significant risk of harm from patients with mental illness, and that they were vulnerable to litigation for actions of negligence and breaches of duty of care that were a direct result of the inadequacy of their education and training. These concerns, coupled with a lack of published literature that might address them, highlighted the need for a deeper understanding of how paramedics accomplish clinical judgement and decision-making of mental illness in the field, and the factors that influence this aspect of their work. Integral to the concerns were questions about the relationship between the formal expectations of paramedic practice—in the form of legislation and clinical policy—and their actual judgement practice in the field. At issue in this study was the preparedness of paramedics to recognise, assess, and manage mental illness in everyday practice and the sufficiency of education and training programs, clinical standards, policy, and legislation for ensuring quality practice and accountability in the field. To understand how paramedics accomplish clinical judgement and decision-making of mental illness in the Queensland pre-hospital emergency care setting and the factors that influence this aspect of their work, this thesis adopted a descriptive theoretical framework of judgement and decision-making (Bell, Raiffa, & Tversky, 1988a) and undertook an interpretive, naturalistic case study according to Stake (1995). In this study, the cases were paramedics, the context was the Queensland pre-hospital emergency care setting, and the issue was how they accomplished clinical judgement and decision-making of mental illness. The study of paramedic clinical judgement and decision-making of mental illness was conducted in two iterative and recursive phases.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Education and Professional Studies
Arts, Education and Law
Full Text

The purpose of this study was primarily to explore the conceptualization of critical thinking development in radiologic science students by radiography program directors. Seven research questions framed three overriding themes including 1) perceived definition of and skills associated with critical thinking; 2) effectiveness and utilization of teaching strategies for the development of critical thinking; and 3) appropriateness and utilization of specific assessment measures for documenting critical thinking development. The population for this study included program directors for all JRCERT accredited radiography programs in the United States. Questionnaires were distributed via Survey Monkey©, a commercial on-line survey tool to 620 programs. A forty-seven percent (n = 295) response rate was achieved and included good representation from each of the three recognized program levels (AS, BS and certificate). Statistical analyses performed on the collected data included descriptive analyses (median, mean and standard deviation) to ascertain overall perceptions of the definition of critical thinking; levels of agreement regarding the effectiveness of listed teaching strategies and assessment measures; and the degree of utilization of the same teaching strategies and assessment measures. Chi squared analyses were conducted to identify differences within each of these themes between various program levels and/or between program directors with various levels of educational preparation as defined by the highest degree earned. Results showed that program directors had a broad and somewhat ambiguous perception of the definition of critical thinking, which included many related cognitive processes that were not always classified as attributes of critical thinking according to the literature, but were consistent with definitions and attributes identified as critical thinking by other allied health professions. These common attributes included creative thinking, decision making, problem solving and clinical reasoning as well as other high-order thinking activities such as reflection, judging and reasoning deductively and inductively. Statistically significant differences were identified for some items based on program level and for one item based on program director highest degree. There was general agreement regarding the appropriateness of specific teaching strategies also supported by the literature with the exception of on-line discussions and portfolios. The most highly used teaching strategies reported were not completely congruent with the literature and included traditional lectures with in-class discussions and high-order multiple choice test items. Significant differences between program levels were identified for only two items. The most highly used assessment measures included clinical competency results, employer surveys, image critique performance, specific course assignments, student surveys and ARRT exam results. Only one variable showed significant differences between programs at various academic levels.
Ed.D.
Department of Educational and Human Sciences
Education
Education EdD

Bakgrund: Väl undersökta psykometriska egenskaper krävs för att använda ett instrument. Instrumentet Reasoning 4 Change (R4C) begreppsvaliditet behöver stärkas. Den kan undersökas genom att jämföra det kliniska resonemanget hos extrema grupper vilka kan vara fysioterapeutstudenter med beteendemedicinsk inriktning i olika skeden av utbildningen. Utifrån den social kognitiva teorin kan fysioterapeutstudenterna ses som en viktig omgivningsfaktor för att hjälpa patienter utföra en beteendeförändring. Syfte: Att utvärdera begreppsvalididet för bedömningsinstrumentet R4C genom att jämföra det kliniska resonemanget med fokus på patienters aktivitetsrelaterade beteende och beteendeförändring hos fysioterapeutsstudenter i termin ett och termin sex mätt med instrumentet. Metod: En beskrivande och jämförande tvärsnittsstudie som utgår från data insamlad ifrån flera tillfällen. Totalt deltog 89 termin ett studenter och 47 termin sex studenter. Parametriskt oberoende t-test användes för att analysera resultatet. Resultat: Termin sex studenterna hade signifikant högre resultat på sju av åtta variabler mätt med R4C jämfört med termin ett studenterna, vilket innebar att hypotesen nästan fullständigt bekräftades. Slutsats: Begreppsvaliditeten kan anses som god för den undersökta populationen. För att generalisering till alla fysioterapeutstudenter ska kunna ske behövs vidare forskning.
Background: Evaluation of psychometric properties are necessary to use an instrument. The Reasoning 4 Change (R4C) instrument’s construct validity needs to be strengthened. It can be done by comparing the clinical reasoning by extreme groups which can be physiotherapy students with a behavioral approach in different stages of the education. From the social cognitive theory's perspective, the students can be an important environmental factor to help clients’ perform a behavioral-change. Aim: To evaluate construct validity for the R4C instrument by comparing the clinical reasoning with focus on clients’ activity-related behaviour and behaviour change by physiotherapy students in the first and sixth semester measured with the instrument. Method: A describing and comparing cross-sectional study with data collected from several occasions. A total of 89 first semester students and 47 sixth semester students participated in the study. Parametric independent t-test was used to analyse the results. Result: Students in the sixth semester had significant higher results on seven out of eight variables measured with R4C compared with students in the first semester, that indicate that the hypothesis almost is confirmed. Conclusion: The construct validity can be considered good for the evaluated population. To be able to generalize to all physiotherapy students more studies would be necessary.

Introduction : l'aptitude à prendre des décisions est cruciale en médecine d'urgence. Notre étude avait pour objectif de mieux comprendre comment les médecins urgentistes prennent des décisions. Méthode : nous avons réalisé une étude qualitative basée sur des entretiens semi-structurés avec des urgentistes. Les entretiens ciblaient la gestion d'une situation d'urgence courante. Ils reposaient sur la visualisation d'une vidéo de l'activité enregistrée en perspective subjective située. Résultats : plusieurs résultats sont originaux. Nous avons en particulier montré le rôle central joué par l'intuition dans la prise de décisions. Par ailleurs, nous avons mis en évidence la façon dont les médecins urgentistes génèrent et hiérarchisent les hypothèses diagnostiques. Conclusion : l'usage d'une approche méthodologique innovante nous a permis de mieux comprendre la façon dont les urgentistes prennent des décisions, avec plusieurs implications pour la formation
Introduction: the ability to makes decisions is a crucial skill in emergency medicine. Our study aimed at revealing how and when emergency physicians make decisions during the patients' initial management. Methods : we carried out a qualitative research project based on semistructured interviews with emergency physicians. The interviews concerned management of an emergency situation during routine medical practice. They were associated with viewing the video recording of emergency situations filmed in an “own-point-of-view” perspective. Résults : many results are original. Specifically, we showed the major role played by intuition in the decision making process. Moreover, we revealed the way emergency physicians generate and evaluate diagnostic hypotheses. Conclusions : the use of an innovative research method allowed us to better understand the way emergency physicians make decisions in their everyday practice. Our results are associated with several implications for medical education

The ability of the nurse to make clinical decisions is an integral part of nursing practice and clinical competency. The shortage in clinical placement, the incidences of “failure to rescue” and the emphasis on patient's safety has driven the increased use of simulation in nursing education. Yet, there is a lack of evidence about how simulation affects students’ decision-making skills and the way in which nursing students learn how to make decisions is not well understood. The aim of this study was to investigate nursing students’ clinical decision making using high fidelity simulation of a deteriorated patient scenario. Twenty-three nursing students in the final year of their nursing degree were recruited for this investigation. A pragmatist approach and a multiphase mixed method design were adopted. The Health Science Reasoning Test (HSRT), think aloud and observations were used in phase1. A semi-structured interview was applied in phase 2 to explore the benefits of this experience on students' clinical practice. Phase 1 results showed a statistically significant improvement in the overall HSRT score post the simulation experience. The students applied both methods of reasoning, the forward and backward, in a dynamic manner to make decisions. They predominantly used the analytical type of decision making and forward reasoning to respond to a patient's deterioration. The equal application of the analytical and non-analytical types associated with a better effect on the HSRT score. The students were not always effective in cue acquisition and interpretation and these stages were affected by cognitive biases. Phase 2 revealed that simulation promoted deep learning and increased students' self-awareness. The study draws the attention to the need for a clinical simulation design that based on a theory of decision making. It proposes a framework that has the potential to enhance the effectiveness of clinical simulation in teaching clinical decision making.

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Introduction: Multi-disciplinary team members predict each patient’s rehabilitation potential to maximise best use of resources. A lack of underpinning theory about rehabilitation potential makes it difficult to apply this concept in clinical practice. This study theorises about rehabilitation potential drawing on everyday decision-making by Health Care Professionals (HCPs) working in stroke rehabilitation services. Methods: A clinical scenario, checked for face validity, was used in two focus groups to explore meaning and practice around rehabilitation potential. Participants were 12 HCPs working across the stroke pathway. Groups were co-facilitated, audio-recorded and fully transcribed. Analysis paid attention to data grounded in first-hand experience, convergence within and across groups and constructed a conceptual overview of HCPs’ judgements about rehabilitation potential. Results: Rehabilitation potential is predicted by observations of “carry-over” and functional gain and managed differently across recovery trajectories. HCPs’ responses to rehabilitation potential judgements include prioritising workload, working around the system and balancing optimism and realism. Impacts for patients are streaming of rehabilitation intensity, rationing access to rehabilitation and a shifting emphasis between management and active rehabilitation. For staff, the emotional burden of judging rehabilitation potential is significant. Current service organisation restricts opportunities for feedback on the accuracy of previous judgements. Conclusion: Patients should have the opportunity to demonstrate rehabilitation potential by participation in therapy. As therapy resources are limited and responses to therapy may be context-dependent, early decisions about a lack of potential should not limit longer-term opportunities for rehabilitation. Services should develop strategies to enhance the quality of judgements through feedback to HCPs of longer-term patient outcomes.Implications for Rehabilitation Rehabilitation potential is judged at the level of individual patients (rather than population-based predictive models of rehabilitation outcome), draws on different sources of often experiential knowledge, and may be less than reliable. Decisions about rehabilitation potential may have far reaching consequences for individual patients, including the withdrawal of active rehabilitation in hospital or in the community and eventual care placement. A better understanding of what people mean by rehabilitation potential by all team members, and by patients and carers, may improve the quality of joint decision making and communication.

Os enfermeiros no âmbito das boas práticas de cuidados elaboram um raciocínio para desenvolverem o processo de cuidados. Mas o modo como o desenvolvem durante a prestação de cuidados não é expresso pelos enfermeiros, e no mundo académico o processo tem sido pouco explorado. Motivo pelo qual decidimos investigar a dimensão processual do raciocínio clínico, pesquisando os conceitos que o suportam e as relações que estruturam o processo. E sob uma metodologia compreensiva e pragmática deixámo-nos guiar pelo método da teoria fundamentada. Criámos uma amostra teórica a partir da análise de narrativas, observação, notas de campo e entrevistas com os enfermeiros de uma unidade de cuidados intermédios, em contexto hospitalar. Os dados reunidos permitiram analisar 980 interações e estas foram codificadas com o apoio da microanálise e de um programa informático. Na codificação aberta criámos 202 categorias, na codificação axial reduzimos para 11 e na seletiva reduzimos para 4 conceitos de natureza complexa. Resultaram da análise os conceitos - ambiente de cuidados, informação clínica, conhecimento clínico e tomada de decisão clínica. Entre estes conceitos formam-se relações que geram uma unidade global e um comportamento que é dinâmico. E esta estrutura que é processual move-se recursivamente num movimento em espiral, com reciprocidade entre os quatro conceitos. O que lhe dá um potencial generativo integrativo e recursivo. A partir destes resultados criámos uma teoria substantiva e um modelo que explica a dimensão processual do raciocínio clínico dos enfermeiros numa unidade de cuidados intermédios. Concluímos que no contexto de um ambiente securizante se desenvolve um processo de cuidados, no qual as suas diversas partes se interrelacionam, numa dinâmica recursiva, integrativa e generativa que permite integrar sistematicamente novos dados, e isso determina uma constante alteração do rumo dos cuidados. Todo o processo é acompanhado por um sistema de decisão partilhada, que reduz a incerteza e aumenta a segurança na equipa de cuidados.
Nurses, in the context of good care practices, develop a reasoning to develop the care process. But the way they develop it during the provision of care is not expressed by nurses, and in the academic world the process has been little explored. That is why we decided to investigate the procedural dimension of clinical reasoning, researching the concepts that support it and the relationships that structure the process. Under a comprehensive and pragmatic methodology, we were guided by the grounded theory method. We created a theoretical sample based on narrative analysis, observation, field notes and interviews with nurses in an intermediate care unit, in a hospital context. The collected data allowed us to analyze 980 interactions that were categorized with the support of microanalysis and a computer program. In open coding we created 202 categories, in axial coding we reduced them to 11 and in selective coding we reduced them to 4 concepts of a complex nature. The analysis resulted in the concepts - care environment, clinical information, clinical knowledge and clinical decision making. Between these concepts, relationships are formed that generate a global unit and a behavior that is dynamic. And this structure that is procedural moves recursively in a spiral movement, with reciprocity between the four concepts – which gives it an integrative and recursive generative potential. From these results we created a substantive theory that explains the procedural dimension of nurses’ clinical reasoning in an intermediate care unit. We conclude that, in the context of a healing environment, a care process is developed, in which its various parts interrelate in a recursive, integrative and generative dynamic that allows to systematically integrate new data, and this determines a constant change in the direction of care. The whole process is accompanied by a shared decision system that reduces uncertainty and increases safety in the care team.