integratingmedicalandnursingreasoningas corebusiness for ... · workshop program lintroduce...
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Integrating medical and nursing reasoning as core business forthe Nurse Practitioner;
Where do you stand?
Gabriel Roodbol MSc M ANP
WORKSHOP 28-8-2018 14:30-15:30
NO CONFLICTS OF INTERESTS
Aim Workshop
l Exchange clinical experiences with integration of medical and nursing reasoning:– Reflection on nursing reasoning and using classification
systems– Reflection on medical reasoning
Workshop program
l Introduce yourself / context of care / experience (5 min)
l Describe your vision on advanced nursing practice and your ‘personal’ reasoning model & presentation (25 min)
l Short presentation of Levett-Jones clinical reasoning cycle as interdisciplinary model (15 min) (familiair??)
l Discussion and reflection (15 min)
Introduce yourself (short, in 5 minutes!)
[Forming sub groups]l Where are you from? l Specialism / patient populationl Years of experiencel Educated/ trained with which model?l Activities in nursing domain and medical domain
Subgroup (25 minutes)
l Share your vision on ANP and your ‘clinicalreasoning model’
l Discuss differences and similarity’s and write down on flip-over
l Presentation plenary
All disciplines use methodical reasoning
Medical proces (Grundmeijer 2014)
l Complaints/ Symptomsl Problem clearingl Examination (anamnesis & physical exam.)l Differential diagnosisl Additional research (lab/ x-ray / MRI)l Diagnosisl Medical treatment
l Is about health problems
Nursing proces (Gordon, 1994)
l Diagnostic fase– Collect data– Interpretation– Cluster– Diagnose
l Planning outcomesl Planning interventionsl Performl Evaluation
l Is about human respons on health problems
Clinical reasoning cycle (Levett-Jones, 2013)
Clinical reasoning cycle (Levett-Jones, 2013)Context / factsin encounter
patient
Clinical reasoning cycle (Levett-Jones, 2013)Context / factsin encounter
patient
Medical:Chief complaints, history, anamnesis (specific),Review of systems,Additional exam. (Lab., vital, schales, selfreports, etc), family, drugs, medication history, allergies, Etcetera…
Nursing:Functioning:impairments, activity limitations,participation restriction,Personal factorsEnvironmental factors.Functional Health patterns(M. Gordon)
Hetero-anamnesis…
Clinical reasoning cycle (Levett-Jones, 2013)Context / factsin encounter
patient Medical anamnesisNursing anamnesis
Contextualinformation
Personal information
Diagnostic reasoningusing PES-structureand hypodeductive/
analytical model
Clinical reasoning cycle (Levett-Jones, 2013)Context / factsin encounter
patient Medical anamnesisNursing anamnesis
Contextualinformation
Personal information
Diagnostic reasoningusing PES-structureand hypodeductive/
analytical model
Label diagnosis usingNANDA/ ICF/
narrativesICD/ DSM-5
Clinical reasoning cycle (Levett-Jones, 2013)Context / factsin encounter
patient Medical anamnesisNursing anamnesis
Contextualinformation
Personal information
Diagnostic reasoningusing PES-structureand hypodeductive/
analytical model
Label diagnosis usingNANDA/ ICF/
narrativesICD/ DSM-5
Set outcomes (NOC / ICF) in shared decision with
patient
Clinical reasoning cycle (Levett-Jones, 2013)Context / factsin encounter
patient Medical anamnesisNursing anamnesis
Contextualinformation
Personal information
Diagnostic reasoningusing PES-structureand hypodeductive/
analytical model
Label diagnosis usingNANDA/ ICF/
narrativesICD/ DSM-5
Set outcomes (NOC / ICF) in shared decision with
patient
Select Nursinginterventions (NIC) & medical interventions
Evidence based
Clinical reasoning cycle (Levett-Jones, 2013)Context / factsin encounter
patient Medical anamnesisNursing anamnesis
Contextualinformation
Personal information
Diagnostic reasoningusing PES-structureand hypodeductive/
analytical model
Label diagnosis usingNANDA/ ICF/
narrativesICD/ DSM-5
Set outcomes (NOC / ICF) in shared decision with
patient
Select Nursinginterventions (NIC) & medical interventions
Evidence based
Evaluate cure & care based on agreed
outcomes / instruments/ NOC / ICF
Clinical reasoning cycle (Levett-Jones, 2013)Context / factsin encounter
patient Medical anamnesisNursing anamnesis
Contextualinformation
Personal information
Diagnostic reasoningusing PES-structureand hypodeductive/
analytical model
Label diagnosis usingNANDA/ ICF/
narrativesICD/ DSM-5
Set outcomes (NOC / ICF) in shared decision with
patient
Select Nursinginterventions (NIC) & medical interventions
Evidence based
Evaluate cure & care based on agreed
outcomes / instruments/ NOC / ICF
Reflect on personal role, efficacy of
method, organisationand ethics, implications
in society
Reflection on diagnostic reasoning in case of diagnosic faultsBias Definition
Availability bias Pattern recognition and ‘first idea’
Anchoring Lock on salient features in patient presentation too early in diagnosticprocess
Premature closing Premature closing to the decision making process, so that diagnosis is not verified
Blind Obedience To standards, protocol or supervisor
Framing Reasoning based on expertise
Ascertainment bias Thinking is based upon prior assumptions and pre-conceptions(stereotypes)
Diagnostic momentum Once label is attached to patients, they tent to become stickier andstikier.
Fundamental attrubition error Blaming patient for their own ilness
Unpacking principle Failure to collect all relevant cues in establishing a relevant differentialdiagnosis.
Meerendonk, H., Klein, H. (2012). Diagnostische denkfout is te voorkomen, Medisch Contact. Vol 67, nr27,p1648-51.P. Croskerry (2003), importance of cognitive errors in diagnosis and strategies to minimize them. Academic medicine 78(8), 1-6. In Levett-Jones, 2013
Discussion & reflection
l Is it possible to make a distinction between medical and nursing reasoning?
l Is it relevant to your practicel Does the nursing process has an added value in NP?
Which? l Does models such as NANDA-NIC-NOC or ICF have
an added value?l Where do you stand? / What is your point of view?l What did you learn?