Identifying And Avoiding Clinical Reasoning Bias In Nursing Practice

A clear understanding of the clinical reasoning cycle remains important. In your previous written assessment task in this unit, you were required to explore a clinical encounter up to and including the ‘evaluation’ stage. In this paper, the focus is on extending your ‘evaluation’ phase of the cycle within that encounter and ‘reflect on new learning’ to close the cycle. Therefore, revisiting your clinical reasoning encounter analysis (Part B) is strongly advised.

Additionally, within Part B, you were required to select an encounter where something didn’t go to plan or was missed, etc. In this paper (Part C) you are going to explore ‘why’ it didn’t go to plan by selecting TWO of the nine clinical reasoning errors that potentially contributed to this as identified by Levett-Jones. -The clinical reasoning errors are detailed in the final module for this unit and will also feature in the week 9 workshops.

Clinical Reasoning Bias in Nursing Practice

The given case is based on the health condition of a 47-year-old female who was currently shifted to the medical rehabilitation for the purpose of the ongoing physiotherapy needs mainly because she had had a left knee tibial plateau fracture following a mechanical fall with the non-operative management in Westmead hospital. When the patient was admitted to the hospital she had no past medical history neither any allergies. Initially no such problem was assessed with the patient, however after two days the patient showed symptoms like sore throat and headache. Till then no such signs of the actual health condition has been identified by the health professionals. Only after the temperature of the patient spiked up to 39. 5 degree Celsius while the vital signs was checked for, then a note was made of the deteriorating health condition. At that time no such observation or assessment was made which helped in the detection of the occurrence of influenza A. when the temperature had spiked so high, the nurse on duty had provided the patient with 1-gram pandadol PO, which only helped the patient ton get an intermittent sleep.  About three hours after this incident, it was noticed that the patient has become febrile with high temperatures 37.2-degree Celsius along with which she complained of symptoms like sore throat, headache and shivering. This was the time when the nurse professionals present on duty realised that the signs might be of influenza that too since a day before there had been a case where another patient had shown similar symptoms like Mrs M, which made the nurses on duty to think that she too might be suffering from influenza A.

The staff failed to identify the fluA in the first instance itself mainly because the nurses failed to assess the cues properly. This was mainly because of the presence of overconfidence on the part of the nurses which was accompanied along with ignorance which was a result of the overconfidence. One of the significant errors in clinical reasoning that had been conducted by the nurses was that the fluid balance chart of the patient had not been checked properly. Another error that had been conducted was that no such physical or laboratory assessment have been conducted on the patient immediately after the symptoms have occurred. This was mainly a result of the judgement overconfidence which is an important bias in clinical errors. The lack of proper identification of the flue A in the first instance can fall under the clinical reasoning bias of anchoring. According to Guerrasio and Aagaard (2014), tendency to fixate on the first impression or selected signs or symptoms results in mis-diagnosis or late diagnosis and falls under the category of anchoring bias. As per the case study, the escalating body temperature was thought to be a manifestation of the tibial plateau fracture. Thus at first instance flue A was not considered. After the symptoms have emerged and the temperature of the patient had spiked up to as high as 39.5 degree Celsius accompanied with the conditions like headache, muscle aches, loss of appetite, dehydration and general weakness, the fluid charts of the patient was viewed. While viewing it was come across that the say before the fluid intake of the patient was quite less and no urine has been passed out since midnight. In terms of nutrition too, the patient was seen to consume in very less amounts. This condition although was observed was neglected by the nurses and was thought to be a result of the upper respiratory tract infection, which had led to the occurrence of inflammation. However later this was understood to be a result of the viral infection that had led to the immune response and reaction to the viral infections which produces the viral syndrome like high fever, coryza and body aches (Belongia et al. 2015).It was after this realization that the nurse in change decided to conduct tests like urine test, blood test and nasal swab and conduct certain clinical reviews. All the above cues were not detected properly which was a result of the overconfidence that led to biasness. This results in erroneous inflation of the probability of being correct and taking the right clinical judgement. Overconfidence occurs when perceived confidence exceeds judgment correctness. 

Case Study on Failure to Detect Influenza A

In order to redeem the situation several observations, assessments and swabs were conducted. When the results of the nasal swabs were obtained it showed positive result of influenza A. Then patient continued to show the symptoms as pervious along with the necrosis of the cells of the respiratory tract in addition to the inflammatory response and high fever (van Asten et al. 2016). The problem that had initially arise that is the rise in the temperature of the patient was remedied by encouraging the patient to take up enough fluids and also by conducting a blood culture. The blood test helped to identify the condition of hyperthermia. In order to remedy the situation it was also important to carry out regular assessments and continuous monitoring of the vital signs. PRN medication for vomiting and temperature was administered. Anti-pyretic medication and PRN anti emetic medications was administered according to the medication chart (Shells and Morrell-Scott 2018). The primary problem that has been identified in the context of the given case showed major ignorance on the part of the nurses. Firstly there was a documentation error. The nurses should be accurate regarding the documents which keeps a track of all the changes in the condition of the patient in a timely manner (Zikhani2016). Ignorance of the documents is a major pitfall in nursing because this shows that they are not efficient enough to manage time during their duty hours. In turn this also neglects the safety of the patient which can be avoided if the patient is monitored regularly and then document interventions are performed. Once the changes are documented, it is important to report these changes are required to be informed to the nurse managers or supervisors to avoid the adverse events (Klindworth 2014). All the signs and symptoms of distress of the patient should be immediately monitored. It is the duty of the nurses to ensure that the documents are on the correct patient and that they are followed regularly. Another factor that is associated with unpacking bias. For the purpose of maintaining health equity, it is important to unpack one’s own unconscious bias since it can be troubling at times. This unpacking biasness led to the occurrence of health disparity in the given situation that led to the development of negative interactions between the healthcare provider and the patients.

From the given situation I have learnt the importance of avoiding errors since these might have a serious impact on the health care services and quality of the patient. The clinical reasoning that had been provided failed to observe several cues hence there is a possibility to improve the reasoning cycle in future. In terms of improving my professional practice, I will have to adopt certain changes in my nursing practice that will help me to provide better care to the patients in future. From the situation I have understood that bias, whether it is intentional or unintentional can create lots of barriers between the patients and the nurses. There is a negative evaluation which might be involved in such a situation (van Asten et al. 2016).

Impact of Bias on Patient Care

For us nurses it is very important to be sensitive to the elimination of the cultural biasness in order to provide optimum care. Acknowledgment is another factor which should be implemented in my practice in future. Knowing the fact that bias exists and that it can affect the patient in a negative way, it is very important for us to admit that bias might be a part of our interactions with others, therefore without acknowledging, it is very difficult to eliminate. The other factors that should be taken into consideration are empathy, advocacy and education (Singh and Sittig 2015).  I will also work my psychological skills in order to reduce the sense of over-confidence and will treatment the children with care and effective critical thinking under evidence-based practice in order to prevent the development of over-confidence and anchoring bias.

In the future I will try to overcome my biased thinking in order to encourage other to challenge my opinions and ideas. I have noticed that the best decision in taken when all the aspects of a situation are taken into consideration which might also include the uncomfortable situations. It is important to be aware of and identify the personal feelings about cultural, socioeconomic, and personal choice differences and work to remove them from their patient interactions and care; which in turn will help to treat the patients in a better way. It has been reported that one of the greatest contributors of serious medical errors is the presence of miscommunication among the nurses especially during their change in shift (Zikhani, 2016). Therefore this leads to the serious injuries and deaths from medical errors. There is a need to avoid diagnostic errors. The mistakes that occur with diagnosis not just only include the factor of wrong diagnosis, it also involves the incidences of delayed diagnosis, partial diagnosis or over diagnosis. Therefore after considering all of this, it can be concluded that we as nurses are required to think proactively regarding the current practices along with the opportunities for the harms and the errors before a mistake is done. It is important to advocate the system-wide analyses of procedures which might leave the practitioners vulnerable to the errors. It is important for us nurses to understand the consequences of the mistakes made and also to acknowledge them in the change of the practice. If this is followed there might be reduction of the medical errors and in turn early detection of the disorder (Guerrasio and Aagaard 2014).

References

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Belongia, E.A., Sundaram, M.E., McClure, D.L., Meece, J.K., Ferdinands, J. and VanWormer, J.J., 2015. Waning vaccine protection against influenza A (H3N2) illness in children and older adults during a single season. Vaccine, 33(1), pp.246-251.

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Shells, R and Morrell-Scott, N 2018, ‘Prevention of dehydration in hospital patients’, British Journal of Nursing, vol. 27, no. 10, pp. 565–569, viewed 8 January 2019, CINAHL Complete database.

Singh, H. and Sittig, D.F., 2015. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf, 24(2), pp.103-110.

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van Asten, L., Bijkerk, P., Fanoy, E., van Ginkel, A., Suijkerbuijk, A., van der Hoek, W., Meijer, A. and Vennema, H., 2016. Early occurrence of influenza A epidemics coincided with changes in occurrence of other respiratory virus infections. Influenza and other respiratory viruses, 10(1), pp.14-26.

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Zikhani, R., 2016. Seven-step pathway for preventing errors in healthcare. Journal of Healthcare Management, 61(4), pp.271-281.