Clinical Decision-making Skills Research Articles

Major challenges and barriers in clinical decision-making as perceived by emergency medical services personnel: a qualitative content analysis

BackgroundHaving to work in unpredictable and critical conditions, emergency care services (EMS) personnel experience complicated situations at the scene of accidents which, inevitably, influence their clinical decisions. There is a lack of research into the challenges which these professionals encounter. Accordingly, the present study aims to explore the major challenges and barriers which affect clinical decision-making from the perspective of EMS personnel.MethodsThe present study is a qualitative work with a content analysis approach. Selected via purposeful sampling, the subjects were 25 members of the EMS personnel in Iran who met the inclusion criteria. The study lasted from December 2019 to July 2020. Sampling was maintained to the point of data saturation. Data were collected using semi-structured, in-depth, individual interviews. The collected data were analyzed via qualitative content analysis.ResultsThe results of data analysis were categorized into four themes and eight categories. The main themes were professional capabilities, occupational and environmental factors, inefficient organizational management, and ethical issues.ConclusionThe results of the present study show that clinical knowledge, experience, and skills contribute to emergency care personnel’s professional capabilities in making clinical decisions. Good teamwork skills and time management can prevent feelings of confusion when the number of the injured to be attended to is large. Effective clinical decision-making skills can not only help the personnel make the right decision, but enhances their resilience and enables them to adapt to hard and unpredictable conditions. Professional factors, organizational management, and ethical matters constitute the other major factors which influence the clinical decision-making of emergency care personnel at the scene of accidents and determine the quality of their clinical performance. Thus, it is essential that pre-hospital emergency care managers improve the quality of EMS personnel’s clinical decision-making skill.

Flipping the Classroom to Optimize Clinical Decision-Making in the Didactic Setting.

Deliberate inclusion of clinical decision-making nursing skills in the didactic setting will assist students in potentially making better patient care decisions. This can be optimized through use of the flipped learning andragogy. Flipped learning promotes an interactive classroom environment. It fosters teamwork and collaboration. Direct content instruction is the responsibility of students. This cohort pilot study investigated how the flipped and nonflipped approach to teaching impacted clinical decision-making and student participation. The Clinical Decision-Making in Nursing Scale (CDMNS) was administered to the students in the flipped classroom and the nonflipped classroom on week 1 and week 6. A student participation checklist was used to observe class activities at three separate intervals (baseline, mid-semester, and end-semester). A repeated measures analysis of covariance was conducted with Instruction Group as the between subjects factor (Flipped and Nonflipped) and Time (preinstruction and postinstruction) as the within subjects factor, and covarying age. The Time by the Instruction group was significant. The Flipped group showed an increase in Clinical decision-making scores (p < .001) after instruction while the Nonflipped group did not (p = .40). The Flipped group (n = 24) showed an increase in Clinical decision-making scores (p < .001) after instruction while the Nonflipped group (n = 23) did not (p = .40). The Flipped classroom showed 100% participation at baseline, mid-semester, and end of semester. The Nonflipped classroom showed overall lower levels of participation, with 42%, 33%, and 39% at each point respectively. Students who were taught using the flipped instruction were able to apply what they learned in relevant case studies, virtual simulations, and practice National Council Licensure Examination RN (NCLEX-RN) type questions. Through teamwork and collaboration, students had time to practice clinical decision-making skills. This was evident in the increased CDMNS scores and increased levels of participation over time in the flipped group when compared to the nonflipped group.

Diagnostic Decisions of Language Complexity Using Informal Language Assessment Measures.

The current study aimed to understand the clinical decision-making skills of school-based speech-language pathologists (SLPs) using narrative and expository discourse information from three sources: perception of language through listening to language alone, standardized criterion-referenced narrative assessment data, and word- and morpheme-level language sample analysis data. Twenty-eight current school-based SLPs participated in the study. During this study, participants rated language quality and made decisions regarding the provision of language services after being provided information from informal assessment measures. SLPs' ratings of language quality and complexity varied across the story retell, wordless picture book generation, and expository samples. There was a lack of consistency in ratings within each context across areas of clarity, sample complexity, language complexity, and vocabulary across all SLPs. Self-reported factors that influenced SLPs' ratings included components of structure, syntax, and semantics. SLPs did not indicate a need for services after listening alone. When provided with criterion-referenced narrative assessment scores and word- and morpheme-level language sample data, more SLPs made a recommendation for services. The study demonstrates the need for objective language measure data during diagnostic decision making. Additionally, SLPs may not realize the information obtained from real-time perception, and analysis of language samples may be an unreliable and inconsistent picture of a child's language abilities. The results of this study highlight the need to continue to rely on multiple sources of assessment data. SLPs should continue to incorporate systematic methods to minimize variability of perceptions in the process of making diagnostic decisions. https://doi.org/10.23641/asha.17707451.

Understanding safety-netting in remote consulting

The COVID-19 pandemic has changed the way health care is delivered. Paul Silverston explains the importance of providing appropriate safety-netting advice in remote consultations In primary care, the COVID-19 pandemic caused a rapid switch from face-to-face to remote consulting, which presented few opportunities for nurses who were unfamiliar with remote consulting to undergo any training in this skill. The clinical assessment and clinical decision-making skills required in remote consulting are different from those in face-to-face consulting and there is also a higher risk of diagnostic and decision-making errors in remote consulting than in face-to-face consulting. Safety-netting is an essential part of safe practice in primary care to reduce the risk of serious harm to patients from these errors. This article discusses the principles and practices of safety-netting in remote consulting.

Three Speech-language Pathology Graduate Programs, One Model: Using Systematic Instruction to Develop Students’ Clinical Decision-making Skills

To prepare graduate students to implement evidence-based practice effectively, educators must integrate instruction on rational clinical decision-making into course curricula. Three faculty members at different universities adopted an educational approach derived from the Rehabilitation Treatment Specification System (RTSS) to teach and assess clinical decision-making in the context of treating acquired cognitive-communication disorders for people with traumatic brain injury. Using treatment theory illustrated in the RTSS, the authors piloted instruction and assessment materials to examine potential usefulness of the approach and effects on student knowledge and confidence in clinical decision-making. The results indicated that the instructional approach effectively bolstered students’ knowledge of and confidence implementing memory-based cognitive-communication intervention. Additionally, using a case-based assessment tool, the authors were able to measure how students modified treatment activities in response to different contextual variables. Implications and suggestions for implementing theory-based instruction in graduate education are discussed.

Learning by doing: To explore the influence of Simulation on Clinical Decision-Making Approaches on Final Year Medical Students at the University of Duisburg-Essen, Germany.

This article was migrated. The article was marked as recommended. Background: Final year medical students at the University Duisburg-Essen, Germany, are unsatisfied with their clinical judgement skills in common elective and emergency clinical situations. A competency based medical curriculum determines that clinical judgement is an essential tool in effective patient care, patient safety and limiting clinical error. Approaches to clinical judgement include either analytical, intuitive or a combination of both approaches. Novices show specific factors, which are typical in inexperienced clinicians. Simulation provides opportunities in a competency-based medical education curriculum. There is limited evidence showing that simulation can provide an effective environment for teaching and learning clinical decision-making skills. This project explores how final year medical students at the University of Duisburg-Essen approach the clinical decision-making process as well as how simulation influences this process. Methods: Ethics approval was obtained from the local ethics committee. After completing a 10-week simulation course,thirty-five students completed a clinical decision-making instrument to categorise their clinical decision-making approaches. The Novice Decision Making Model and the Cognitive Continuum Model were combined with learning theories in Simulation (Social Cognitive Theory) and used to explore and interpret data collected through questionnaires, interviews and observation. Results: The majority (60%) of students employed a predominantly analytic approach, some students showed intuitive tendencies in clinical situations. During interviews students displayed typical novice approaches to decision-making and expressed positive comments relating to simulation. Conclusions: Simulation presents an opportunity for teaching and learning clinical decision-making. Results show the need for further inquiry into learning clinical decision-making through simulation. This research provides initial evidence that simulation can be incorporated into curricular teaching of clinical decision-making.

Student Pharmacists’ Response to a Pandemic: Service-Learning through Contact Tracing

In March 2020, the SARS-CoV-2 (COVID-19) pandemic disrupted education nationwide. To safely deliver in-person classes, Purdue University contracted One-to-One Health, creating the Protect Purdue Health Center (PPHC). The PPHC was a central location for information, testing, and case management for Purdue students, staff, faculty and their dependents. Contact tracing is a proven public health measure that has been utilized to control the spread of infectious diseases by identifying and isolating potential active cases. The communicative nature of contact tracing, along with its need for clinical decision-making skills makes the student pharmacist an ideal candidate for aiding in this pandemic response. In an effort to support the PPHC in navigating the necessary protocols to keep Purdue open, operating, and safe, the College of Pharmacy formed Experiences in Public Health, a service-learning course which enrolled ten student pharmacists. The students served as contact tracers, participated in group discussions surrounding emerging COVID-19 health information, and reflected on their experiences as members of the community. As contact tracers, they aimed to decrease secondary spread of COVID-19 by identifying and following-up with close contacts of lab-confirmed cases, educating on quarantine/isolation protocols, and scheduling tests for those with symptoms or exposure history. Active participation in a pandemic response is a meaningful opportunity for professional growth in patient-centered care and communication. Students actively improved upon skills taught in the Doctor of Pharmacy program such as motivational interviewing, active listening, and open communication to fulfill their role as contact tracers. Additionally, the students gained proficiency in patient education and clinical decision-making, and through class discussions, enhanced their abilities to answer COVID-19-related questions with scientific resources. Through volunteering at the PPHC and engagement in peer-led topic discussions, the Experiences In Public Health service-learning course allowed student pharmacists to apply professional skills to become an active force in mitigating the spread of COVID-19. This service-learning opportunity provided several key takeaways. Student pharmacists who participated in this initiative attest that they are more comfortable providing patient care, better able to handle a rapidly developing clinical situation, and further prepared for their future careers in various fields of pharmacy practice.

Vigilance in Nurses Working in Intensive Care Units

Background and Aim: Vigilance is an essential element in intensive care nursing. This study was conducted to determine nursing vigilance in nurses working in the intensive care units of educational and medical centers in Ardabil, Iran. Methods: This was a cross-sectional descriptive-analytical study with 192 ICU nurses as the participants. The data were obtained through questionnaires regarding demographic characteristics and nursing vigilance. SPSS software version 24 was used for the statistical analysis. Results: The mean total vigilance score was 3.86 ± 0.23 of 5. The mean scores of the timely diagnosis of changes, pattern recognition, and clinical decision-making subscales were 4.07 ± 0.26, 04.04 ± 0.41, and 3.44 ± 0.25, respectively. No significant relationships were observed between the total or subscale vigilance scores and other demographic characteristics. Conclusion: We assessed ICU nurses’ vigilance behaviors and found that their mean vigilance score was higher than the expected average, indicating our participants had a high level of clinical vigilance. These results suggest a need for effective educational interventions to boost clinical decision-making skills in ICU nurses, especially younger nurses.

Using a behavioural framework to optimize antibiotic prescribing by family medicine residents.

This article was migrated. The article was marked as recommended. Background and objectives:Overprescribing of antibiotics in primary care is a prominent concern in the context of increasing antimicrobial resistance worldwide. Medical trainees are a key group to deliver thoughtful antimicrobial stewardship training. This study examined the factors influencing antibiotic prescribing for upper respiratory tract infections (URTI) by family medicine residents in order to identify educational interventions. Methods: Using purposive sampling of family medicine residents, semi-structured interviews were conducted until thematic saturation was reached. Interviews were coded into the domains of the Theoretical Domains Framework (TDF). Belief statements were created to characterize each domain and categorized as enablers or barriers to appropriate prescribing. Domains were plotted on the Behaviour Change Wheel (BCW) and intervention functions identified. Results:Twelve participants were interviewed. Nine domains of the TDF were relevant to antibiotic prescribing. Social influence was a prominent theme with the preceptor and patient being key influences on resident prescribing. Learning goals were also a key theme including the desire to strengthen independent clinical decision-making skills and improve antibiotic knowledge. Residents' beliefs about capabilities were challenged when faced with diagnostic uncertainty. Additional domains included: professional role; environmental context and resources; intentions; beliefs about consequences and capabilities, and knowledge. Using the BCW, nine intervention functions were identified to change antibiotic prescribing behaviour. Conclusion: This study found nine domains of the TDF were relevant to family medicine resident antibiotic prescribing for URTI. Nine intervention functions could be used to guide intervention design.

Effectiveness of an Advanced Clinical Decision Support System on Clinical Decision-Making Skills in a Call Center Medication Therapy Management Pharmacy Setting: A Pilot Study.

(1) Background: There is limited evidence related to the efficacy of advanced clinical decision support systems (CDSS) on the quantity of high-quality clinical recommendations in a pharmacy-related medication therapy management (MTM) setting. The study aimed to assess the effect of an advanced CDSS on the quantity of relevant clinical pharmacist recommendations in a call center MTM setting. (2) Methods: This pre-test/post-test with comparator group study compared clinical skills assessment scores between certified MTM pharmacists in March 2020. A Wilcoxon Signed Rank test assessed the difference between pre- and post-test scores in both groups. (3) Results: Of 20 participants, the majority were less than 40 years old (85%) with a Doctor of Pharmacy degree (90%). Nine were female. Intervention group participants had less than three years of experience as a pharmacist. The control group had less than three years (40%) or seven to ten years (40%) of experience. There was a significant increase in intervention group scores between pre- (median = 3.0, IQR = 3.0) and post-test segments (median = 6.5, IQR = 4.0, p = 0.02). There was no significant change between control group pre- and post-test segments (p = 0.48). (4) Conclusion: Pharmacist exposure to an advanced CDSS was associated with significantly increased quantity of relevant clinical recommendations in an MTM pharmacy setting.

Judgment and decision-making in clinical dentistry.

The development of clinical judgment and decision-making skills is complex, requiring clinicians—whether students, novices, or experienced practitioners—to correlate information from their own experience; from discussions with colleagues; from attending professional meetings, conferences and congresses; and from studying the current literature. Feedback from treated cases will consolidate retention in memory of the complexities and management of past cases, and the conversion of this knowledge base into daily clinical practice. The purpose of this narrative review is to discuss factors related to clinical judgment and decision-making in clinical dentistry and how both narrative, intuitive, evidence-based data-driven information and statistical approaches contribute to the global process of gaining clinical expertise.

A Method Model Presentation: Online Clinical Mentoring for Physical Therapists Experiencing Professional Isolation

Background and Purpose. Clinical mentoring is essential for the professional development of physical therapists (PTs) and improves confidence and clinical decision making. Physical therapists working in professionally isolated settings with the lack of contact with professional peers face unique challenges, including lack of access to mentors, which can result in diminished job satisfaction, recruitment, and retention. The innovative use of technology, including videoconferencing, can help address the challenges faced by these health care providers by improving access to clinical mentoring. The purpose of this study was to examine the effects of an online model of clinical mentoring on PTs experiencing professional isolation in an outpatient musculoskeletal setting. Method/Model Description and Evaluation. Eight professionally isolated and 4 expert PTs were divided into 4 groups. Three 1-hour online case-based mentoring video sessions were held over the course of 5 weeks. Data were collected from pre and postparticipation surveys and postparticipation focus groups. A mixed-methods analysis was used to evaluate data. Outcomes. Qualitative results for the mentee group revealed 4 themes: perspective, reflection, perceived clinical benefits, and feasibility. Three themes emerged for the mentor group: accessible model, advancing the profession, and perspective. Quantitative analysis revealed significant improvement in 4 areas of confidence. All participants felt that the intervention supported professional attributes; 75% of participants reported the group size as ideal, and 75% of mentees felt that the program improved both confidence and clinical decision-making skills. Discussion and Conclusion. Online clinical mentoring can address several of the barriers faced by PTs who work in professional isolation and allows PTs who would not otherwise have access to postprofessional education to access a mentor remotely.

In search of Kipling’s six honest serving men in upper limb rehabilitation: within participant case-crossover experiment nested within a web-based questionnaire

Purpose In search of Kipling’s six honest serving men in upper limb rehabilitation after stroke, we sought to investigate clinicians’ perspective of when and where to begin therapy, how much and what therapy to provide, and who and why (or not) to provide therapy. Materials & methods: Within-participant case cross-over experiments were nested within an anonymous web-based questionnaire (21 questions, three cases). Graph theory-based voting to produce ranked ordered lists and mixed-effect logistic regression were performed. Results In total, 225 Australian stroke clinicians responded: 53% occupational therapists, 61% working in acute/inpatient stroke setting. Most respondents indicated they did not have a protocol/expectation regarding when (62%), how much (84%) or what (60%) therapy to provide in their setting. Respondents ranked 24-h to 7-days post-stroke as the optimal time to commence therapy, and 30- to 60-min per day as the optimal dose to provide. Within-participant experiments demonstrated that greater motor recovery as time progressed increased the odds of offering therapy, while lack of motor recovery, shoulder pain, neurological decline and sole therapist reduced the odds. Conclusion We need to develop an evidence base concerning Kipling’s six honest serving men and equip clinicians with clinical decision-making skills aligned with this focus. IMPLICATIONS FOR REHABILITATION Most clinicians did not have access to a protocol / clinical pathway which defines when, how much and what upper limb therapy to provide after stroke, which may be improved by providing individual clinicians with organisational support to make therapy decisions. To improve the personalisation of upper limb rehabilitation in clinical practice, we need to understand when and where after stroke to begin therapy, how much and what therapy to provide, as well as who and why (clinical decision-making) to provide therapy. Clinicians perceive clinical trials as successful if the therapy can demonstrate recovery that is greater than a minimal clinical important difference (MCID).

Implementing virtual experiences and remote assessments during the COVID-19 pandemic: A college experience

With nine weeks remaining in the term, COVID-19 necessitated emergency remote learning and remote online exams. This required a series of software trainings for administrators, faculty and students at Howard University College of Pharmacy, USA. The experiential department also had to look beyond normal clerkship placements. The described telemedicine and virtual experiences were used to supplement face-to-face experiences. Assessments for both learning innovations were successful, based on faculty and student feedback. Student reflections describe how COVID-19 helped advance the use of telehealth and indicate their learning of clinical decision-making skills, effective communication, and the digital health industry. A formal evaluation of outcomes from the implemented pandemic innovations is being planned. The use of online proctoring with artificial intelligence during the emergency remote learning was successful. With software training, this type of service can be adopted to ensure the integrity of assessments. The cost of the service and the reporting time should be considered in academic planning.

The predict of metacognitive awareness of nursing students on self-confidence and anxiety in clinical decision-making.

This study was conducted to investigate the affect that metacognitive awareness in nursing students has on self-confidence and anxiety with respect to clinical decision-making. The sample for this descriptive, correlational, and cross-sectional study consisted of 186 nursing students who voluntarily participated. Data were collected using the Metacognitive Awareness Inventory and Nursing Anxiety and Self-Confidence with Clinical Decision-Making Scale. Correlation and regression analyses were then performed on the data. Nursing students' metacognitive awareness level explained the three subdimensions of self-confidence in clinical decision-making by 26.7% (r2 = 0.267, p < 0.01), 24.6% (r2 = 0.246,p < 0.01),and 26.8% (r2 = 0.268,p < 0.01), respectively. Nursing students' metacognitive awareness level explained the three subdimensions of anxiety in clinical decision-making by 3.7% (r2 = 0.037,p < 0.01), 3.2% (r2 = 0.03, p < 0.05), and 2.4% (r2 = 0.024,p < 0.05), respectively. Clinical decision-making skills can be supported by increasing students' metacognitive awareness.

University of Nevada, Reno School of Medicine

University of Nevada, Reno School of Medicine

The Effects of a Problem-Based Learning (PBL) Strategies on Nurse Practitioners' Critical Thinking Skills, Communicative Competence, and Clinical Decision-Making Skills in Nursing Education

The Effects of a Problem-Based Learning (PBL) Strategies on Nurse Practitioners' Critical Thinking Skills, Communicative Competence, and Clinical Decision-Making Skills in Nursing Education

The Utility of Virtual Patient Simulations for Clinical Reasoning Education.

Virtual Patient Simulations (VPSs) have been cited as a novel learning strategy, but there is little evidence that VPSs yield improvements in clinical reasoning skills and medical knowledge. This study aimed to clarify the effectiveness of VPSs for improving clinical reasoning skills among medical students, and to compare improvements in knowledge or clinical reasoning skills relevant to specific clinical scenarios. We enrolled 210 fourth-year medical students in March 2017 and March 2018 to participate in a real-time pre-post experimental design conducted in a large lecture hall by using a clicker. A VPS program (®Body Interact, Portugal) was implemented for one two-hour class session using the same methodology during both years. A pre–post 20-item multiple-choice questionnaire (10 knowledge and 10 clinical reasoning items) was used to evaluate learning outcomes. A total of 169 students completed the program. Participants showed significant increases in average total post-test scores, both on knowledge items (pre-test: median = 5, mean = 4.78, 95% CI (4.55–5.01); post-test: median = 5, mean = 5.12, 95% CI (4.90–5.43); p-value = 0.003) and clinical reasoning items (pre-test: median = 5, mean = 5.3 95%, CI (4.98–5.58); post-test: median = 8, mean = 7.81, 95% CI (7.57–8.05); p-value < 0.001). Thus, VPS programs could help medical students improve their clinical decision-making skills without lecturer supervision.

Conceptualisation and development of the RIPE-N model (reflective interprofessional education-network model) to enhance interprofessional collaboration across multiple health professions

ABSTRACT This paper describes a novel model of learning, designed to enhance interprofessional education (IPE) and interprofessional collaboration (IPC). Lessons learned, plans for sustainability and future directions for policy, practice, implementation, and curriculum training are also discussed. The RIPE-N model (Reflective Interprofessional Education – Network model) was developed for an interprofessional simulation environment involving five health professions – pharmacy, nursing, orthoptics, physiotherapy, and speech pathology with the potential to increase the number of health professions involved. The RIPE-N model was adapted from the original RIPE Model (Reflective Interprofessional Education Model), utilising unfolding multidisciplinary case from admission through to discharge. Key adaptations of RIPE to include a greater focus on professional practice and the opportunity for collaboration by all disciplines. Reflection is critical to the RIPE-N model to develop the reflective practitioner, hence the inclusion of collaborative reflective (‘pause and reflect’) stations aimed at improving collaborative clinical decision-making skills among diverse healthcare professionals.

Nursing Students’ Perceptions of Nursing Diagnoses and Clinical Decision-Making

Objective: The objective of this study was to evaluate nursing students’ perceptions regarding nursing diagnoses and clinical decision-making skills level and to examine how these perceptions differ according to which nursing model was followed.Methods: A descriptive, cross-sectional, comparative study was conducted. The study was carried out in one nursing department in Istanbul province and one nursing high school in Çanakkale province, Turkey. A total sample of 257 students participated. A Structured Information Form, Perception of Nursing Diagnoses Survey and Clinical Decision Making in Nursing Scale were used to collect data.Results: 77.1% of the participants were women, with an average age of 19.09, and their average grade from the Fundamentals of Nursing course was 74.23 ± 9.41. The total of the PND score for the ADLs group was 2.45 ± 0.55, in the FHP group it was 2.31 ± 0.27. This difference in the incidence of value was not significant. The total of the CDMNS score means of the ADLs group was 147.44 ± 12.95, and the mean of the FHP group was 154.3 ± 12.29. A statistically significant difference was detected between the groups for the CDMNS score (p = 0.00). Conclusion: From the results, it can be concluded that the use of nursing diagnoses is positively perceived by nursing students and their clinical decision-making perceptions are in the process of development. Nursing models that are used in nursing education may affect clinical decision making.