Clinical Reasoning as a Key Element of Preventing Iatrogenic Harm In the Process of Nursing Care

Research article

Clinical Reasoning as a Key Element of Preventing Iatrogenic Harm In the Process of Nursing Care

Corresponding author: Jefferson Garcia Guerrero, Fakeeh College for Medical Sciences, Al Hamra District, Jeddah, Saudi Arabia. Email: jgguerrero@fcms.edu.sa

Abstract

Background: Nursing incorporates independent and collaborative care of people regardless of age, family, group, community, and health condition.  It promotes health, prevents sickness, cares for the sick, and manages the disabled and the dying.

Purpose: Healthcare professionals have the primary concern to give their level-best service to all patients, regardless of socio-economic status.  The conduct of this study drew its basis on the increasing cases of medical conditions brought about iatrogenic harm to various patients under the care of nurses.

Methodology: The cross-sectional design using descriptive survey, taking nurses at Dr. Soliman Fakeeh Hospital in Jeddah, Saudi Arabia as respondents.  The baseline information was collected from a Demographic Performa while clinical reasoning skills were assessed through a Script Concordance Test.  Script Concordance Test assessed the clinical reasoning in uncertain situations and allowed real life situation testing.  Quantitative data were gathered with the use of structured questionnaire while qualitative data were accessed through interviews that brought in observation for simplified data. The summary of data is in form of frequency and percentage.

Result: Iatrogenic harm was mostly accounted by the respondents for medication errors (78.02%). While mismanagement was identified by 14.28% of the respondents, a total of 6 or 6.59% of them answered combination of medication and mismanagement. A respondent considered medication, laboratory testing, diagnostic, and mismanagement as the causes of iatrogenic harm.  Data revealed the relevance of clinical reasoning in the prevention of iatrogenic harm.

Discussions: Results suggest that utilization of clinical reasoning with participants in this study and iatrogenic harm could both happen in the clinical setting. Notwithstanding the high percentage of participants who never experienced iatrogenic harm, addressing it through clinical reasoning could not be established in this study.

Acknowledgments: The researcher drew inspiration from healthcare professionals and practitioners in nursing research who incessantly contributed to the pool of knowledge which addresses various challenges in the profession, particularly in improving nursing practice.

Keywords: Clinical Reasoning; Iatrogenic Harm; Nursing Care; Key Element

Introduction

Nursing incorporates independent and collaborative care of people regardless of age, family, group, community, and health condition.  It promotes health, prevents sickness, cares for the sick, and manages the disabled and the dying.

Nursing care plans and the innovations that take place vary in workplace. They evolve well over time from technologies to strategies.  To improve medical settings with innovative technologies and organization, barriers are now identified and dealt with by heightening the degree of skills and techniques and implementation of training programs to mold and enhance these skills.

As theories are broken down into practice in a holistic understanding and point of view, nursing responsibilities are viewed as not confined merely on a medical aspect but also include other facets like the social part. Social responsibility plays a significant role in a nurse-patient relationship. Regarding nursing culture, changes took place to empower them as respectable and important allies in the clinical field.

Patient care is now enhanced with technological advancements, as the leaps and bounds of nursing professionals grow continuously adapting to the needs and changes of every patient.  With the changes that happen to revolutionize the clinical environment, the medical arena becomes a respected place for comfort, care, and wellness.

In the opinion of Nendaz & Peirrier (2012)[1], there are inaccuracies in diagnostics pertaining to adversative occurrences in medication while more than 30% in negligence privileges and these could relate towards the work setting but reasoning disputes are of 75% involvement in relationship to systemic failure.  The error in data integration, data collection, and data verification, as well could result to early diagnostic closing.  There is a need in increasing understanding, avoidance and modification of medical inaccuracies.  Healthcare professionals must involve their own reasoning, decision process, and evidence-based researches to enhance error prevention.

Today, the nursing arena is evident with drastic changes.  These changes are aimed at bringing efficiency in the medical care.  With the plethora of training programs and better hospitals, come bigger scope of responsibility, more intimate sense of family, and well-directed focus on patient care.  These saved lives and honed better generations of nursing professionals and paved the way to correct flaws and innovate practices.

Entailing extensive understanding, skills, and flexibilities, a nurse holds a profession of improved clinical reasoning to get through the barriers of health care including iatrogenic harm. In like manner, it is a responsibility which incorporates critical views in the course of management and a role of playing both as a team member and a leader.  More importantly, every detail in the course of treatment is as important as the other.

Clinical Reasoning

For Lee et al. (2016) [2], appropriate cyclic clinical reasoning skills are being applied by nurses even in complex medical practice and that, educational strategies will enhance competency in an accurate and timely manner.

Clinical reasoning, also known as clinical judgment, is a method where medical professionals gather signs, develop evidences, understand the patient’s medical situation, design and act on appropriate medical involvements, assess results, then absorb from this entire method [3].

This considers several phases of patient care as well as making the right decision for patients’ treatment, diagnosis, and prevention to enhance quality care as well as clinical skills.  Nurses face critical application of clinical reasoning in complex situations.  The phase of clinical reasoning fortifies the skill, reflects learning, achieves improved results, and avoids related incidences for the years to come [4]

 Iatrogenic Harm

In the case of errors in the hospital setting, Cresswell et al [5] summarized those specific areas that are recognized to merit additional study including relationship among healthcare workers and patients, collaboration in the medical group, investigations in laboratories and diagnostics, problems in managing statistics, evolutions in varied care sites, and completion of patients’ records.

Review of evidence identified that morbidities resulted by iatrogenic harms are not measured and arguments regarding avoidance happen in private and restricted scenes [6]. The art of safety progressed to define how diagnostic errors, inadequate skill, communication breakdowns, and poor judgment can harm patients and result to death. In achieving reliability in the healthcare systems, there should be improved safety coming from national and international data as being utilized by researchers handed down to clinicians and other practicing healthcare professionals.

Makary & Daniel (2016) [7] inferred that thorough systematic procedures starting with problem assessment remain critical in dealing with every patient with health risk and iatrogenic harm is not an exemption following these systematic steps.

Meanwhile, Nendaz & Perrier (2012) [8] stated that inaccuracies in diagnostics are primarily perceptive not relating deficit in knowledge but on the relevance of patients’ records along with its incorporation and confirmation of investigative hypothesis.  This means that the danger of incidence raises in the actual setting of hard run-through especially when time is critical and medical professional utilize heuristics that are of partialities.  These biases are associated to personal traits, environment, and mental depiction of disease and this may prompt early diagnostic closure.

Nendaz & Perrier (2012) [8] identified ways to prevent errors and these include self-awareness, trainings, and external support.  Firstly, doctors must indulge interest in creating diagnosis and judgments through adaptation of evidence-based approach to medical learning concerns instead of depending simply on their feelings.  Next to this is education, teaching, training, supervising healthcare professionals in the context of clinical practice.  Lastly, prior, after and continuing learning must deliver explicit training to aid doctors identify and correct the errors in their cognitive skills.

 Nursing Care

Johnsen et al. [7] utilized newly graduate nurses concentrated on broad nursing ideas detailed in areas needed along with responsibilities offered for homecare service in different groups of patient. The study resulted utilization of nurses’ modest and multifaceted rational developments that involves reasoning of inductive or deductive type.  This contributed to effective nursing programs. Competent specialized training needs skills on motor action from mental activity, emotions, and compound thinking [8]

Conceptual Framework

The clinical reasoning cycle is a self-motivated process that combines one or two steps or move to and from prior making a decision, action, and evaluation. Levett et al [8] stated the importance to recognition, understanding and working through each steps than making assumptions on patients’ problems and instantly making interventions that lack adequate considerations.  Iatrogenic harm can be prevented with these effective skills.

To look is to consider the patient’s situation.  This is where description or listing of facts, objects, or people takes place. In collecting cues or information, it is incorporating reviews, current information and gained knowledge.  This pertains to the medical breakthroughs and learned theories along with evidence-based practices. Processing of information utilizes interpretation data, discrimination relevant from irrelevant information, discovering relationships, inferring deductions or opinions, matching situations from past to current, and predicting outcomes.

There is a need for consideration of clinical reasoning.  One is the right cues.  O’Neill et al [9] identified these cues that are predisposed with varieties of causes like nervousness, skill, self-confidence, and pressure. Therefore, reflection and questioning are vital in assumptions and prejudices to positively impact cue achievement and patient outcome.  The right patients are those at risk of illnesses and adverse medical events. Jacques et al. [10] came up with the possibility that adversative result scaled up with patients who had 2 or 3 delayed warning signs.

Identifying patients at risk will bring better management and outcome.  The right time is about knowing the primary cautioning signs and the late cautioning signs and to know their difference and clinical judgment is always bounded by time.

Rescue fails not only because of failed recognition of early signs but also when intervention is carried out late. The right action should foster therapeutic communication and practical skills.  These prompt nurses to knowing priorities based on involved plans and actions.  Lastly, the right reason includes moral, lawful, and qualified standards.  This means that the right reason is not merely applicable to the practice of reasoning but the sustaining foundation and therefore, this kind of right must be loaded with this foundation [8]

Healthcare professionals have the primary concern to give their level-best service to all patients, regardless of socio-economic status.  The conduct of this study drew its basis on the increasing cases of medical conditions brought about iatrogenic harm to various patients under the care of nurses. The study was guided by the following objectives: (1) Identify the effects of clinical reasoning in the prevention of iatrogenic harm; (2) Identify iatrogenic harms in the medical setting; (3) Describe the management/ practices used for iatrogenic harms; and (4) Identify the barriers in clinical reasoning?

 Methodology

The cross-sectional design using descriptive survey, taking nurses at Dr. Soliman Fakeeh Hospital in Jeddah, Saudi Arabia as respondents. The baseline information was collected from a Demographic Performa while clinical reasoning skills were assessed through a Script Concordance Test.  Script Concordance Test assessed the clinical reasoning in uncertain situations and allowed real life situation testing.  This is reflected the degree of concordance of judgment. It allowed testing on real-life situations that are not adequately measured with current tests and probed the multiple judgments that are made in the clinical reasoning process. Scoring reflects the degree of concordance of these judgments to those of a panel of reference experts. Quantitative data were gathered with the use of structured questionnaire while qualitative data were accessed through interviews that brought in observation for simplified data. The summary of data is in form of frequency and percentage. This research was approved by the Institutional Review Board of the hospital where it was conducted.

Results

Table 1 exhibits the summary of the nurses’ responses when asked the phase of the nursing process where they utilized clinical reasoning. Data gathered revealed that nurses applied clinical reasoning during assessment (65.9%), management (26.37%), critical episodes (2.19%), assessment and management (3.29%), and using all ways (2.19%).

Data further confirmed that the avenues in encountering and learning critical reasoning include experience (63.73%), school (college/univ) (20.88%), evidence-based researches (3.29%), school and experiences (8.79%) and combining all avenues (3.29%).

Asked if they can easily identify iatrogenic harm, 49.45% of the respondents answered in the affirmative. While 39.56% of the respondents they can sometimes identify iatrogenic harm, 10.98% of them claimed that they cannot.

A total of 58 or 63.73% of the respondents claimed that they can incorporate self-reflection skills in clinical reasoning, while 33 or 36.26% of them believed that they sometimes can. Of the 91 participants, 20 or 21.97% sometimes experience it, 9 or 9.89% claimed that it happens most of the times, and 62 or 68.13% never experienced it.

Table 1: Clinical Reasoning Results

 

When asked on the relevance of clinical reasoning in the prevention of iatrogenic harm, 6 or 6.59% of the respondents believed that it is irrelevant, and 6 or 6.59% said that it is less relevant. While 56 or 61.53% of the respondents believed in the relevance of clinical reasoning in the prevention of iatrogenic harm, 23 or 25.27% of them answered even claimed that it is very relevant.

Participants were able to list usual risks of iatrogenic harm which included pressure ulcers, medication error, adverse drug reaction, negligence, complication of surgery complication of medication procedure, medications and diagnostic exam, medication error, medication and negligence, unperformed aseptic technique, medication, hospitalization, wrong dispensing of medications, malnutrition, mistakes in surgery procedure, immobilization, infections, medical errors, adverse drug reaction, falls, nosocomial infection, delirium and pressure ulcers.

Table 2 summarizes the identified causes mostly contributing to iatrogenic harm. A total of 71 or 78.02% of the respondents identified medication. Mismanagement accounts for 13 or 14.28% while 6 or 6.59% of the respondents answered combination of medication and mismanagement. Meanwhile, a respondent considered medication, laboratory testing, diagnostic, and mismanagement as the causes of iatrogenic harm.  (Table 2)

Table 2: Iatrogenic Harm

The 91 participants listed the following elements in clinical reasoning: experience, nursing intervention, critical management, clinical judgment, technique, problem solving, assessment and  intervention, decision making, diagnostic and evaluation, critical thinking, planning, nursing diagnosis, nursing plan, performing proper assessment and carrying out the steps according to protocol and policies, collecting cues, processing information, understanding the problem/situation, evaluating outcomes, reflecting and learning from the process, and patient related experience or participation, in patient care, nursing knowledge, feedback, reflection, usability and collaboration.

The participants also identified the elements of nursing efficiency which covered the following: experience on the area of designation, nurses’ conscience, nurses’ dignity, social skills and experiences, nursing quality to improve, establish quality learning system, being caring and helpfulness to others to achieve the ultimate goal, productivity, effectiveness, skillfulness, professionalism and competitiveness, development of emotional intelligence, integrity for one’s self, development of critical thinking in decision making, dedication to work, good communication skills, respect to patient needs, and safe and quality nursing service.

Discussion

Data suggest that clinical reasoning is incorporated during assessment, learned because of experiences, utilized self-reflection, relevant in preventing iatrogenic harm, and with essential elements.  These elements include experience, nursing intervention, critical management, clinical judgment, technique, problem solving, assessment &  intervention, decision making, diagnostic and evaluation, critical thinking, planning, nursing diagnosis, nursing plan, performing proper assessment and doing the steps according to  protocol and policies, collecting cues, processing information, understanding the problem/situation, evaluating outcomes, reflecting and learning from the process, and patient related experience or participation, in patient care, nursing knowledge, feedback, refection, usability and collaboration.

With the same set of participants, identification of iatrogenic harm is easy for 50% and the other half are those that can sometimes identify such harms and those who cannot.  This can be explained by the high leverage of those who never experienced iatrogenic harm over those who less to mostly experienced it.  Medication is the most identified cause of iatrogenic harm and based on the usual risks listed by the participants, most pertain to medication reasons like medication error, adverse drug reaction, negligence, complication of surgery, complication of medication procedure, medications and diagnostic exam, medication error, medication and negligence, unperformed aseptic technique, hospitalization, and wrong dispensing of medications.  Results suggest that utilization of clinical reasoning with participants in this study and iatrogenic harm could both happen in the clinical setting. Notwithstanding the high percentage of participants who never experienced iatrogenic harm, addressing it through clinical reasoning could not be established in this study. Thus, additional studies are encouraged to explore this area.

 References

  1. Nendaz, M., & Perrier, A. Diagnostic errors and flaws in clinical reasoning: Mechanisms and prevention in practice. Swiss Med Wkly 2012; 23(142): w13706.
  2. Lee J, Lee YJ, Bae J, et al. Registered nurses’ clinical reasoning skills and reasoning process: A think-aloud study. Nurse Educ Today 2016; 46:75-80
  3. Brown E. Clinical Reasoning: An Important Aspect of Clinical Skill Lifestyle.
  4. European Heart Association. (2018). The Clinical Reasoning Cycle: The 8 Phases and their Significance.
  5. Cresswell KM, Panesar SS, Salvilla SA, et al. Global Research Priorities to Better Understand the Burden of Iatrogenic Harm in Primary Care: An International Delphi Exercise. PLoS Medicine 2013; 10(11).
  6. Makary MA, & Daniel M (2016). Medical error-the third leading cause of death in the US.
  7. Johnsen H, Slettebø A, Fossum M. Registered nurses’ clinical reasoning in home healthcare clinical practice: A think-aloud study with protocol analysis. 2016; 40:95-100
  8. Levett-Jones T, Hoffman K, Dempsey, et al. The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Educ Today.2010; 30(6): 515-520.
  9. O’Neill E. Dluhy N, Chin E. Modelling novice clinical reasoning for a computerised decision support system. J Adv Nurs. 2005: 49 (1): 68-77.
  10. Jacques T, Harrison G, McLaws M, et al. Signs of critical conditions and emergency responses (SOCCER): a model for predicting adverse events in the inpatient setting. Resuscitation 2006; 69 (2):175-183.

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