Rethinking clinical decision-making to improve clinical reasoning

Exploring professional reasoning in occupational therapy: A scoping review of recent research

Background

Professional reasoning in occupational therapy has become a key line of research. Updating and analyzing recent publications is crucial for the discipline. The objective of the research was to describe new findings and changes in the characteristics of research on professional reasoning in occupational therapy between 2019 and 2023.

Method

A scoping review was used with the aim of identifying the development and scope of the literature on professional reasoning in occupational therapy from 2019 to 2023. The review was conducted in five stages following the PRISMA-ScR guidelines.

Results

Seventy-six articles were described in terms of their nature and volume under the following categories: specific fields of practice, educational strategies for professional reasoning, theoretical discussions, and instruments related to professional reasoning. New findings include two professional reasoning modalities, five practice-related areas, and intervention programs that had not been previously described. Additionally, there has been an increase in the use of mixed methods.

Conclusion

This scoping review identifies the nature and volume of literature on professional reasoning in recent years. The study reveals consolidated research lines focused on practice and teaching, alongside new findings and changes observed in recent studies.

Confidence, Barriers, and Role Identity of General Practice Independent Pharmacist Prescribers in Northern Ireland

Background: The role of General Practice Independent Pharmacist Prescribers (GPIPPs) has expanded significantly in primary care, with increasing responsibilities in medicines optimisation and chronic disease management. However, gaps remain in understanding their confidence in clinical decision-making, the barriers they face, and their professional identity within multidisciplinary teams. This study aimed to explore GPIPPs' confidence, identify barriers to their prescribing autonomy, and assess the clarity of their role and their support within primary care settings in Northern Ireland. Methods: A cross-sectional study design was employed, combining quantitative and qualitative approaches. Data were collected via a Jisc online questionnaire distributed to GPIPPs working in general practices across Northern Ireland. The questionnaire assessed their demographic information, confidence in clinical decision-making, barriers to prescribing, and professional identity. Qualitative data from open-ended responses were analysed using thematic analysis. Results: Quantitative findings indicated that most GPIPPs viewed clinical decision-making as integral to their role, yet only a few felt adequately prepared by their independent prescribing courses. Qualitative analysis revealed themes such indemnity concerns, insufficient training, role ambiguity, and variability in GP support. Conclusions: The study highlights that while GPIPPs are confident in their prescribing roles, significant barriers such as indemnity concerns, training gaps, and role ambiguity hinder their full potential. Policy-level changes, including clearer indemnity policies, enhanced training programs, and standardised mentorship, are essential to optimise GPIPPs' integration and effectiveness in primary care. Addressing these challenges will ensure that GPIPPs can fully contribute to patient care as autonomous prescribers.

Effects of Stigmatizing Language on Trainees' Clinical Decision-Making in Substance Use Disorders: A Randomized Controlled Trial

OBJECTIVES

Substance use disorder (SUD) continues to be one of the most stigmatized and under-treated conditions in the United States. Stigmatizing language used by healthcare workers can transmit bias to others within healthcare, including medical trainees. This study investigates how stigmatizing language and undergraduate medical education (UME) curricula may influence trainees' clinical decision-making for patients with SUD.

METHODS

Medical students from three Chicago-area medical schools were randomized to review either a stigmatizing or neutral version of a clinical scenario describing a patient experiencing opioid withdrawal. Participants (a) selected treatment plans for the fictional patient using two multiple-choice questions, (b) completed the Medical Condition Regard Scale (MCRS) to assess their attitudes, and (c) reported prior SUD experiences, both curricular and personal. Statistical analyses explored whether treatment decisions were influenced by attitudes, addiction medicine curricula, and exposure to the stigmatizing vignette.

RESULTS

Among the 366 medical students who completed this study, exposure to stigmatizing language (n = 191) led to clinical decision-making that would be less effective in treating opioid withdrawal for the fictional patient (p = 0.027; η2 = 0.013). Exposure to more SUD education during UME was correlated with more effective clinical decision-making for opioid withdrawal (β = 0.181; R2 = 0.033; p < 0.001) but was not correlated with attitudes toward patients with SUD (p = 0.231).

CONCLUSIONS

Stigmatizing language influences clinical decision-making when treating patients with SUD. Improving SUD education within UME may be an effective strategy for mitigating this effect within medical trainees.

Clinical reasoning and decision making within the role of a palliative care advanced clinical practitioner

Advanced clinical practice invites curiosity, rationalising the reasoning behind clinical symptoms. Developing one's own style of critical thinking is a journey that is influenced by a variety of factors including stress, risk, time and knowledge. There has been significant scrutiny in practice around making a clinical judgement when a person is entering the terminal phases of life, yet little clarity exists for clinicians regarding what information is required to make this decision. Within the role of advanced clinical practitioner (ACP) in palliative care there is an expectation to offer guidance and support to persons and families as well as junior nursing and medical staff of the changing phases of a person's illness. There is 'one chance to get it right', yet predicting death and dying remains predictably unpredictable.

Examining patient safety protocols amidst the rise of digital health and telemedicine: nurses' perspectives

BACKGROUND

Integrating digital health and telemedicine technologies is transforming healthcare delivery. In light of this transition, it is critical to ascertain the efficacy of patient safety protocols and evaluate the awareness of healthcare professionals, particularly nurses, regarding the integration of digital health technologies.

AIM

This study examines the factors influencing the successful adoption of digital health and telemedicine technologies from the nurses' perspective, focusing on ensuring patient safety and enhancing organizational readiness for digital health integration.

METHODS

A cross-sectional study included 246 nurses from outpatient healthcare centers in Egypt. The data collected included demographic information and responses to a series of questionnaires, namely the Patient Safety Culture Survey (PSCS), the Telemedicine Risk Assessment and Mitigation Matrix (TRAMM), the Digital Health Adoption Readiness Assessment (DHARA), and the Digital Health Impact Assessment Tool (DHIA). The descriptive statistical analyses were conducted using the IBM SPSS Statistics software, version 26.

RESULTS

The sample was predominantly composed of nurses aged 18-35 (40.65%) and 36-55 (44.72%), with a near-equal gender distribution (48.78% male, 51.22% female). Most nurses held college degrees (73.17%) and were familiar with telemedicine (73.17%). The PSCS indicated positive scores for Communication Openness (4.5), Leadership Support (4.2), Teamwork (4.3), and Organizational Learning (4.1), with an overall mean score of 4.275. The TRAMM scores were notably high (total mean score 4.9), indicating effective risk management. The DHARA demonstrated considerable preparedness, as evidenced by a Total Mean Score of 7.85. The DHIA further substantiated this readiness, indicating a robust anticipated impact, particularly in Patient Engagement (9.0) and Usability (8.2).

CONCLUSION

The favorable assessment scores indicate a strong awareness of integrating digital health and telemedicine, suggesting the potential for enhanced patient care and healthcare delivery. It is recommended that healthcare organizations prioritize providing ongoing training and support for nurses, enabling them to utilize digital health tools and thereby enhance patient safety effectively.

CLINICAL TRIAL NUMBER

Not applicable.

Interprofessional clinical reasoning education

Clinical reasoning is considered one of the most important competencies but is not included in most healthcare curricula. The number and diversity of patient encounters are the decisive factors in the development of clinical reasoning competence. Physical real patient encounters are considered optimal, but virtual patient cases also promote clinical reasoning. A high-volume, low-fidelity virtual patient library thus can support clinical reasoning training in a safe environment and can be tailored to the needs of learners from different health care professions. It may also stimulate interprofessional understanding and team shared decisions. Implementation will be challenged by tradition, the lack of educator competence and prior experience as well as the high-density curricula at medical and veterinary schools and will need explicit address from curriculum managers and education leads.

Mock Wards: Incorporating a Theoretical Framework to Create a Blended Virtual and In-Person Clinical Reasoning Education Platform

Introduction The coronavirus 2019 pandemic highlighted virtual learning (VL) as a promising tool for medical education, yet its effectiveness in teaching clinical reasoning (CR) remains underexplored. Past studies have suggested VL can effectively prepare students for clinical settings. Informed by the Milestones of Observable Behaviours for CR (MOBCR) and whole-case theoretical frameworks, the Mock Wards (MW) program was created using a novel blended in-person learning (IPL) and VL platform. MW consisted of case-based small-group formats for medical students interested in learning approaches and differentials to commonly encountered presenting symptoms and diagnoses in internal medicine. This study sought to use MW's blended design to qualitatively analyze CR development and compare its utility between VL and IPL. Methods Qualitative analysis was conducted using in-depth semi-structured interviews with first-year pre-clerkship medical students (n = 8) who completed the MW program and participated in the study. The interview guide was informed by the MOBCR framework. Interview transcripts were analyzed using a directed qualitative content analysis approach. Translational coding and HyperRESEARCHTM (Researchware, Inc., Randolph, MA) software-generated mind maps guided the theme development. Results Three overarching themes were constructed: (1) tailoring pedagogical frameworks to learning modalities, (2) learning through interactivity, and (3) balancing accessibility with learner engagement. Participants emphasized that teaching CR skills is modality-specific and not fully interchangeable, with IPL being superior in facilitating social cohesion, non-verbal communication, and feedback. In contrast, VL required structured approaches and relied more on verbal communication and pre-made digital materials. IPL also enhanced interactivity, peer relationships, and spontaneous communication, whereas VL faced challenges such as social awkwardness and technological constraints hindering effective collaboration. VL provided superior accessibility to facilitate distributed learning and management of concurrent academic obligations. Conclusion The MW-blended platform highlights the importance of focusing on modality-tailored pedagogies, emphasizing group interactability, and balancing VL accessibility against decreased engagement within the IPL environment when teaching CR skills. Blended education models may benefit from a scaffolding approach, using IPL as a prerequisite to VL to improve CR development and alignment within a learner's zone of proximal development.

Artificial Intelligent Agent Architecture and Clinical Decision-Making in the Healthcare Sector

This paper examines the decision-making processes of physicians and intelligent agents within the healthcare sector, particularly focusing on their characteristics, architectures, and approaches. We provide a theoretical insight into the evolving role of artificial intelligence (AI) in healthcare, emphasizing its potential to address various healthcare challenges. Defining features of intelligent agents are explored, including their perceptual abilities and behavioral properties, alongside their architectural frameworks, ranging from reflex-based to general learning agents, and contrasted with the rational decision-making structure employed by physicians. Through data collection, hypothesis generation, testing, and reflection, physicians exhibit a nuanced approach informed by adaptability and contextual understanding. A comparative analysis between intelligent agents and physicians reveals both similarities and disparities, particularly in adaptability and contextual comprehension. While intelligent agents offer promise in enhancing clinical decisions, challenges with types of dataset biases pose significant hurdles. Informing and educating physicians about AI concepts can build trust and transparency in intelligent programs. Such efforts aim to leverage the strengths of both human and AI toward improving healthcare delivery and outcomes.

The role of information systems in emergency department decision-making-a literature review

OBJECTIVES

Healthcare providers employ heuristic and analytical decision-making to navigate the high-stakes environment of the emergency department (ED). Despite the increasing integration of information systems (ISs), research on their efficacy is conflicting. Drawing on related fields, we investigate how timing and mode of delivery influence IS effectiveness. Our objective is to reconcile previous contradictory findings, shedding light on optimal IS design in the ED.

MATERIALS AND METHODS

We conducted a systematic review following PRISMA across PubMed, Scopus, and Web of Science. We coded the ISs' timing as heuristic or analytical, their mode of delivery as active for automatic alerts and passive when requiring user-initiated information retrieval, and their effect on process, economic, and clinical outcomes.

RESULTS

Our analysis included 83 studies. During early heuristic decision-making, most active interventions were ineffective, while passive interventions generally improved outcomes. In the analytical phase, the effects were reversed. Passive interventions that facilitate information extraction consistently improved outcomes.

DISCUSSION

Our findings suggest that the effectiveness of active interventions negatively correlates with the amount of information received during delivery. During early heuristic decision-making, when information overload is high, physicians are unresponsive to alerts and proactively consult passive resources. In the later analytical phases, physicians show increased receptivity to alerts due to decreased diagnostic uncertainty and information quantity. Interventions that limit information lead to positive outcomes, supporting our interpretation.

CONCLUSION

We synthesize our findings into an integrated model that reveals the underlying reasons for conflicting findings from previous reviews and can guide practitioners in designing ISs in the ED.

Exploring nurses' clinical judgment concerning the relative importance of fall risk factors: A mixed method approach using the Q Methodology

BACKGROUND

Nurses are pivotal in averting patient falls through their assessment of cues presented by patients and their environments, rendering clinical judgments regarding the risk of falling, and implementing tailored interventions. Despite the intricate cognitive processes entailed in nurses' judgment, no prior studies have explored their approach to assessing the risk of falling.

OBJECTIVE

This study aimed to examine how nurses judge the risk of falling among patients with different conditions, whether there are differences in the importance of risk factors as judged by nurses, how they justify their judgments, and what attributes of the nurses influence their judgments.

DESIGN

A mixed method approach using the Q Methodology was employed.

SETTING(S)

Three public and private hospitals in Japan.

PARTICIPANTS

Eighteen nurses participated in the study.

METHODS

Participants were tasked with ranking 36 patient scenarios, each featuring a distinct set of fall risk factors. Subsequently, post-sorting interviews were conducted to gather insights into their typical approach to assessing fall risk and the rationale behind their ranking decisions. A by-person principal component factor extraction was employed to examine differences in the rankings of the scenarios. The interview data were analyzed descriptively to elucidate the reasons behind these discrepancies.

RESULTS

Nurses engage in complex cognitive manipulations when evaluating the risk of patient falls, drawing extensively from their wealth of experience while utilizing assessment tools to support their judgments. In essence, nurses identify patients' tendency to act alone without calling a nurse, impaired gait and cognition, sedative use, drains, and limited information sharing among healthcare professionals as key fall risks. In addition, nurses vary in the importance they attribute to certain risk factors, leading to the discrimination of three distinct judgment profiles. One group of nurses judges patients with cognitive impairment and acting alone as high risk. Another group of nurses considers patients with unstable gait and acting alone as high risk. The last group of nurses sees patients wearing slippers as high risk. The post-sorting interviews revealed that their judgments are closely related to the healthcare context and patient population.

CONCLUSIONS

Nurses operate within diverse contexts, wherein they interact with patients of varying characteristics, collaborate with professionals from diverse disciplines, and have access to varying levels of human and physical resources. This nuanced understanding empowers the formulation of judgments that are finely attuned to the specific context at hand.

STUDY REGISTRATION

Not registered.

Falls as the result of interplay between nurses, patient and the environment: Using text-mining to uncover how and why falls happen

Objectives

This study aimed to explore, from the perspectives of nurses, how patients, the environment, and the practice of nurses interact with each other to contribute to patient falls.

Methods

A retrospective review of incident reports on patient falls, registered by nurses between 2016 and 2020, was conducted. The incident reports were retrieved from the database set up for the project of the Japan Council for Quality Health Care. The text descriptions of the "background of falls" were extracted verbatim, and analyzed by using a text-mining approach.

Results

A total of 4,176 incident reports on patient falls were analyzed. Of these falls, 79.0% were unwitnessed by nurses, and 8.7% occurred during direct nursing care. Document clustering identified 16 clusters. Four clusters were related to patients, such as the decline in their physiological/cognitive function, a loss of balance, and their use of hypnotic and psychotropic agents. Three clusters were related to nurses, and these included a lack of situation awareness, reliance on patient families, and insufficient implementation of the nursing process. Six clusters were concerned with patients and nurses, including the unproductive use of a bed alarm and call bells, the use of inappropriate footwear, the problematic use of walking aids and bedrails, and insufficient understanding of patients' activities of daily living. One cluster, chair-related falls, involved both patient and environmental factors. Finally, two clusters involved patient, nurse, and environmental factors, and these falls occurred when patients were bathing/showering or using a bedside commode.

Conclusions

Falls were caused by a dynamic interplay between patients, nurses, and the environment. Since many of the patient factors are difficult to modify in a short time, the focus has to be placed on nursing and environmental factors to reduce falls. In particular, improving nurses' situation awareness is of foremost importance, as it influences their decisions and actions to prevent falls.

Influencing Appropriate Statin Use in a Charity Care Primary Clinic

According to the American College of Cardiology/American Heart Association (ACC/AHA) new cholesterol management guidelines in 2019, statin regimen was prescribed to only about 46.4% and 30% of diabetes (DM) patients and patients with atherosclerotic cardiovascular disease (ASCVD), respectively. Atherosclerotic cardiovascular disease accounts for most deaths and disabilities in North America. This study argues that a systematic approach to identifying targeted interventions to adhere to the statin regimen for ASCVD is sparse in previous studies. This study seeks to address the research gap. Besides, the study argues that the statin regimen could improve cholesterol management with the enablers of pharmacy, providers, electronic medical records (E.M.R.), and patients. It paves the way for future research on cardiovascular and statin regimens from different perspectives. Current study has adopted the Qualitative observation method. Accordingly, the study approached the charity care primary clinic serving a large population in the northeastern part of the United States, which constitutes the project's setting. The facility has 51 internal medicine residents. The facility has E.H.R., which is used by the clinical staff. Besides, providers use electronic medication prescribing (E-Scribe). Four PDSA cycles were run in six months. Here, the interventions were intensified during each subsequent cycle. The interventions were then incorporated into routine clinical practice. Based on the observation, the study found a 25% relative improvement by six months based on the baseline data of the appropriate intensity statin prescription for patients with ASCVD or DM by medical resident trainees in our single-center primary care clinic. A total of 77% of cardiovascular disease patients were found to be on an appropriate statin dose at baseline. On the other hand, the proportion of patients with DM who were on proper dose statin was 80.4%. According to the study's findings, PDSA could result in a faster uptake and support of the ACC/AHA guidelines. Evidence indicates that overmedication of persons at low risk and time constraints are some of the most significant impediments to the greater use of prescription medications. Proactive panel management can help improve statins' use by ensuring they are used appropriately.