Sample on Clinical Reasoning

Models Of Clinical Reasoning And Their Relevance To Contemporary Practice

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Introduction To Clinical Reasoning

Clinical Reasoning can be considered as a central component towards effective management as well as bringing an overall improvement in overall quality of care that has been patient centered. There has been an increase in overall demand and a presence of highly complex nursing practices related to health care (Harasym, Tsai and Hemmati, 2008). Hence, the clinicians are required to make as well as justify the decisions which are to be based on large number of factors. These are in form of available evidence based, access to health care related resources, issues related to ethics, socio cultural norms and frameworks related to clinical governance as well as professional accountability (Croskerry, 2009).

The given report has tried to lay emphasis on exploration of different models that are related to clinical reasoning followed by understanding nature as well as context of clinical practice. There will further be an exploration on limitations of clinical reasoning so as to enhance the clinicians’ knowledge base. The areas of study has been made to link with a case study of 56 year old painter and decorator named Jim who was suffering from shoulder pain and wants a more accurate diagnosis that was has been given by the physiotherapist.

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The Case Study

The case study is based on a 43 year old police officer who was presented in a clinic with having a history of one week pain in his right shoulder. It was explained by him that pain started to him 7 days before when he woke up in the morning and also experienced a strange feeling in his middle two fingers. His pain increased more when he raised his arms above his head and eased as soon as he stopped the movement that was causing pain. Also, his pain becomes severe in night. After a time period of 3-4 days he experienced a stiffness in his shoulder and found the movement a little more difficult. He does not have a significant past medial history and does not have other health complaints also and was also a keen runner.

Subjective examination

The aim of the subjective examination of the patient suffering from the pain is to find and know about the ethology and with this useful information will be provided to the physiotherapist providing information on the area and behavior of symptoms of the patient suffering from the pain. In other words, in can be said that during the subjective examination of the patient, physiotherapist extract the useful and relevant information about the individual related to history, symptoms so that exact information is known of the patient and all red flags are removed (Cooper, 2013).

The pain as described by the man in the case study took place only before a week and on that day he did a lot of physical work (Jones, 2004). The main symptoms of the pain in shoulder that the police officer was facing mainly included thickening, tightening and swelling of flexible tissue that surrounds the joint of shoulder. This leaves less scope of space in bone of upper arm in the shoulder joint and this eventually makes the movement painful and stiff. With this, it also becomes difficult to make the shoulder movement difficult as well as painful. After observing the symptoms of the patient, another aspect that is included in the subjective examination is the history of pain for the patient (Willcocks, 2012). The individual as per the case study is a 43 year old man and had started pain 7 days ago and was not associated with any kind of injury happened recently. But, the pain started out of the type of daily activities he performed owing to his occupation of police. The pain is more at night and during rising of hand.

The motor physical examination of shoulder pathology of the patient as in the case study examines and gives details about the glenohumeral joint which is the most mobile joint in the human body (Choi and, 2012). But because the occupation of the police is such that it involves a lot of movement this is hampers the joint stability of the glenohumeral joint. As a result, the lack of stability makes the individual more susceptible to injuries especially those involved in sports and in occupation like that of police as in the case. Apart from this, examining of the posture of the patient was also found straight and there was no problem with it. This also includes palpation of the shoulder and provides valuable information on swelling and texture of the shoulder of the patient (Ahonen and Degner, 2012).

With the sensory examination of the patient in the case study having shoulder pain it was observed that there was stiffness in the neck and also a restricted movement in his first ribs. This in turn restricted the way in which nerves moved as they run from the neck and moves down the right arm. This was the main reason behind the strange feeling in his fingers. The muscular assessment of the police officer in the case study was also done and it was observed that all local shoulder muscles tested strong for him except that there was some tightness in the pectoralis minor muscle (Li, 2005). This is at the front of the chest and there was also pain in his scalene muscles which are on the side of neck and those on right were also tight. It was also assessed that there occurred some damage to supraspinatus muscle or tendon. The neurological assessment of the patient can reveal of any kind of numbness in the joint and may warrant of his condition. But this is not observed in the present case and there is only stiffness in his shoulder (Bayley and McKibbon, 2006).

Objective Examination

After the subjective assessment next that need to be carried of the patient is the objective assessment which includes application of specific diagnostic tests. One of them is magnetic resonance imaging (MRI) which is one of the common tests for shoulder pain (Kassirer and, 2009). This is useful for diagnosing rotator cuff tears as well as assessment of muscle and tendon tears. Also, the diagnosis of tear of rotator cuffs of the individual can be done on basis of physical examination and history and this can be confirmed with help of MRI also. Another diagnostic test that can be used for assessing the shoulder pain is X ray in which degenerative changes of the joint can be seen on the imaging (Jackson, 2014). This also assists in the diagnosis of glenohumeral osteoarthritis for the patient if the pain in shoulder has become severe and acute. But this was not the case for the police officer in the case and his pain in joint can be easily diagnosed with physical examination and history. With this, all red and yellow flags can be assessed and thus removed also (Moody and Pesut, 2006). Red flags like severe diseases of liver, heart, Gastric Perforation, peptic ulcer, pancreas and gall bladder as well as fractures do not exist for the patient being considered here. Apart from this, yellow flags like depression, pain syndrome, and lack of family or community support, concurrent psychological illness are all rejected in case of police officer as he is well mentally having full support of his family and having a good social life (Higgs, 2008).

Models Of Clinical Reasoning And Their Relevance To Contemporary Practice

Clinical reasoning can be defined a process where nurses and other clinicians are there to collect cues, process information. This is followed by understanding the problem faced by patient so as to plan as well as implement interventions for evaluating outcomes for reflecting and learning from process (Elstein, 2009). The process is dependent on critical thinking so as to be influenced by attitude of person as well as philosophical Perspective and preconceptions. The process of clinical reasoning cannot be considered as a linear process but is required to be conceptualized as a series or spiral of linked as well as ongoing encounters of clinical origin (Koh and, 2008).

It further entails for a multitude of cognitive processes so as to enable the physicians for combining scientific information with clinical skills as well as experiences faced with similar patients. This will help in making a proper sense of illness faced and to determine the best action that can be taken so as to cure it.

In this regard, there exist varied kinds of models related to clinical reasoning that can be applied so as to make decisions as well as judgment for supporting the process of clinical decision making (Kassirer, 2010).

Client centred model

According to this model, clinical reasoning is considered as a process that involves reflective inquiry in collaboration with the client itself. Through which there is development of in depth understanding of clinical problem by the patient also. This help in providing a sound basis for intervention as a solution to the medical condition (Kuiper and, 2008). The process of reasoning is portrayed by an upward and outward spiral so as to demonstrate clinical reasoning. The model recognizes three core dimensions known as knowledge, cognition and meta - cognition. A sound knowledge base is required by the clinician for effective clinical reasoning and information need to be readily accessible and highly organized (Simmons et al., 2003). Cognition is the thinking ability such as analysis, synthesis and evaluation of data that is collected by the service provider for the patient. Likewise, for the given patient in the case being Jim it is important for the clinician to have proper knowledge on condition of patient and also thinking ability and skills. Meta cognition is the awareness and monitoring of cognitive processes which is an integrative element between knowledge and cognition. This ability is essential for the clinician of present patient Jim in order to accomplish effective problem solving for the client (Higgs and Jones, 2000).

Outcome Present State Test Model

Outcome Present State Test Model also known as OPT is of reflective clinical reasoning that provides for a structure to conceptualize the process of clinical reasoning. The model is further composed of 10 components (Lake and Hamdorf, 2004). These are inclusive of;

  • Patient under study
  • Clinical reasoning web
  • Keystone issue
  • Cue logic
  • Present state
  • Framing
  • Outcome state
  • Testing
  • Decision making
  • Judgments.

It can further be considered as a blueprint so as to assist the students towards organizing the thinking that is involved in process of clinical reasoning. It is also there for providing framework to contrast relation between problem and outcomes and act as a guide for solving the issues (Bland and, 2009). In present scenario, the issue faced by client Jim in terms of shoulder pain is such that its origin cannot be recognizes. Hence, requirement as per given model of clinical reasoning is to write the essential areas of client problems on OPT model worksheet (Bartlett and, 2008). This would be inclusive of name and profession of patient, work profile, identified reasons towards origin of pain, medical diagnoses, assessing medical history of Jim, signs and symptoms, data generated by lab and other diagnostic as well as social/family history (Hendrick and, 2009).

In the same way, clinical reasoning web can be regarded as a pictorial representation to identify functional relation among diagnostic hypotheses that is derived from synthetic thinking due to convergence in identifying the central issues that need urgent care (Kuiper and, 2008). The web in case of Jim will assist in promoting clinical reasoning by having an overview of client's story so as to identify as well as represent issues and needs that have been revealed by patient.

These will act as a major guideline towards the process of clinical reasoning. The next step as per the model will be to map out as well as visualize the relation that exists among medical and nursing diagnosis (Hogarth, 2005). The model will thus assist in ensure towards making decisions/judgments followed by support clinical decision making. It will assist in providing reasoning about clinical situations faced by Jim so as to ensure for meeting up proper patient care needs. It will further provided a guideline for nursing staff towards carrying out a primary diagnosis in order to decide on nursing care needs on account of stipulated medical condition. The nursing staff will become more conscious so as to make s proper sense of situation faced by patients (Kuiper and Kurtz, 2009).

Dual-process theory: an emerging model

Dual-process theory can be defined as that model of reasoning which tries to integrates the processes that have been identified in the areas of clinical reasoning research since the time span of 1970s. It allows for making the doctors understand as to how they think as well as reason in every day practice (Dawes, Summerskill, Glaszious and et al., 2005). The theory has given a considerable amount of research to the phenomenon of intuition. It further plays a major role towards making decisions.

This theory has been stemmed out from the works done in mid-1990s in the area of cognitive psychology by Epstein and Hammond. Here, there is a presence of two separate systems which can be used for clinical reasoning (Adler and Rodman, 2003). The first has been described as intuitive’, ‘tacit’ and ‘experiential. It can further be considered as a reflex system where triggers have been found to occur in automated mode. It is there to produce intuitive response which is generated without putting in many efforts and is also below the prescribed threshold of perceptible consciousness (Arnold and Boggs, 2011).

This so called intuitive system has been found to be rapid where visual information that is available readily is made to operate on the principle of recognition. In case of Jim the clinical reasoning can be based on comparing the signs and symptoms with the ones that have been observed in situations similar to present ones. The generate responses in case of given case of Jim have been found to bear high dependence on contextual cues. This system has been negated by many researches on account of reliability of intuition (Albanese, 2006). Some of them have a view point that although the given system of intuition is very effective in terms of time but is found to be a lot more vulnerable towards error while undertaking the process of clinical reasoning (Crosskery, 2009).

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The second system can be described as analytical’, ‘deliberate’ and ‘rational. In comparison to first system which was of intuitive origin, the present one has been found to be more analytical’, ‘deliberate’ and ‘rational in nature (Ahuja and Williams, 2005). The clinical reasoning has been found to come out from rational as well as deliberate judgment that is based on additional information that has been collected by individual in the given environment. The present system has however been considered to be slow enough and is also very demanding in terms of cognition.

A few theorists are of opinion that response that is generated by analytical system may not be better than intuitive system (Hogart, 2005). In spite of the prevailing grey areas, the given model can be utilized for present case study of Jim, to provide for a comprehensive as well as useful view of clinical reasoning.

Hypothetico-deductive model of clinical reasoning

This model has been proposed by Mark Jones. Here, there is an involvement of self reflection so as to carry out an informed process of decision making for generating as well as testing the hypothesis in relation to presenting the signs and symptoms of patient. It further considers that clinical reasoning is not just dependent on setting but has been found to be more influenced by the cognitive skills as well as perceptual processes of knowledge, cognition and meta-cognition that are present with the clinicians (Atkinson and Nixon-Cave, 2011). The mode in case of Jim can thus be applied for carrying out a thorough medical diagnosis of his condition so as to generate as well as test hypothesis which is based on clinical data and knowledge. However, the model has been criticized on the grounds that there is a non occurrence in a sequential manner (DiCenso, Cullum and Ciliska, 2002). This is in terms of various sub processes that are involved in area of problem solving. They are not sequential but still have a possibility orb occur on a simultaneous level. In the same way, arguments have also been laid that there is a no specific usage of hypothesis generation as well as testing in terms of medicine but has been found to be characteristic of mature adult cognition (Hendrick and 2009).

It is further found out that the Hypothetic-deductive model of clinical reasoning is therapist centered and has usually been found to ignore the role of patient in the overall process of decision making. Owing to the above criticisms that were made by several researchers there has been an adoption in this model. It has been made to adapt who the area of physiotherapy practice. The model can further be used in context of Jim by laying emphasis on the circular nature of entire reasoning process in comparison to just diagnosis. It further emphasis on the significant contributing that can made by Jim towards the process of clinical reasoning. Research studies have further proposed that the given model can be applied for generation of hypothesis within five major categories (Kumar, Kumar and Sisodia, 2013). These are inclusive of identifying the source of the symptoms being faced by Jim, contributing factors that have caused an increase in shoulder pain, undertaking precautions as well as contraindications to physical examination, carrying out measures related to proper treatment, management as well as prognosis.

Introduction to Clinical Reasoning Process

Consider patient situation – The given step of process will entail for describing the context being faced by patient (Bleakley and, 2003). This 56 year old patient has been suffering from shoulder pain which radiates into his right medial deltoid muscle. Hence the patient situation in form of issues, signs as well as symptoms is required to be given a due emphasis so as to formulate a process of clinical reasoning.

Collect information – it involves for reviewing the current set of information. These may be in form of patient history, reports, results of previous investigations as well as nursing and medical interventions that have been undertaken previously (Samanta and Samanta, 2005). It may further involve for gathering new set of information as well recalling them. In present case, Jim fell from ladder 10 years ago. He has been suffering from neck and back pain since six months. He also lost 2 kilograms due to attending of weightwatchers. It has also been found out that Jim has been working on a daily basis of twelve hours as a painter for past three months. It is only by collecting the requisite information; there can be a creation of proper reasoning in terms of above mentioned attributes that are linked to Jim.

Process information – This area will involve for analyzing the data so as to assess the prevalence of signs and symptoms by comparing the normal with abnormal in case of Jim. There is further a need to differentiate relevanent facts and figures from irrelevant ones (Choi and, 2012). This will assist in recognizing of consistencies so as to narrow down information as to what is most significant and which requires recognizing gaps in cues. Processing of information may further involve for discovering new relations so as to cluster the cues together and identify the existing relations (Mackenzie and Watts, 2011). Inference may also be required to make so as to make deductions as well as formulate opinions about the prevailing nature of pain that has been found to follow logically from the information. It will further help in putting a due consideration towards alternatives. Then there will be a matching of current situation to past followed by predicting the outcomes (Choi and, 2012).

Identify issues – The next necessity happens to be carrying out a thorough synthesis about facts and inferences so as to make a diagnosis about the issue or problem that is being faced by Jim.

Establish goals – This step involves for establishing goals by describing what the clinicians are expecting to happen. This is in terms of desired outcome as well as time span (Kellett, Clarke and Matthews, 2005). The established goals in present scenario can be helping Jim get rid of pain so that he can continue with the work in a best possible manner.

Take action – After establishment of goals, there is a requirement to select a course of action from the different alternatives that are available in front of the clinician (Noll, Key, and Jensen, 2001). In present case, after clinical reasoning, there is a possibility that Jim may be provided with a lot of options for treatment. Hence, the requirement on part of healthcare professionals that are working for Jim is to identify actions to be taken in context of the stipulated problem.

Evaluate outcome – This area of study entails for evaluating the effectiveness of outcomes as well as actions (Kapur, 2009).

Reflect on process and new learning – Here, there is a requirement towards contemplating about what has been learnt from the process of clinical reasoning (Paul and Elder, 2005). This is required in order to assess what can be done differently.

Role Of Knowledge And Practice Epistemology In Shaping Advanced Clinical Reasoning And Developing Practice

An essential role is played in terms of knowledge and practice epistemology so as to shape the advanced clinical reasoning as well as developing practice. It is also true that there is a presence of interdependent relation between Knowledge and clinical reasoning (Edwards and, 2004). Moreover, different forms of knowledge have been found to be valuable to attain a level of skilled practice as well as sound kind of clinical reasoning (Elstein, 2009).

Clinical reasoning can only be done properly is knowledge that arises from clinical expertise is combined with that of patient preferences as well as evidences in research studies (Eva, 2005). The researcher are also of the view point that clinical reasoning involves for making a choice of discrete range of options, so as to make an evaluation about available set of information (Gordon, 2006). In this regard, there is a presence of many knowledge areas that are required to be shaped so as to shape the area of clinical reasoning.

Knowing oneself- It is required on part of clinicians that they are aware about their own behavior, competencies, attitudes, emotions and values. Along with this, awareness is also required about patient or client being handled by them (Trede and Higgs, 2003). For example, in context of present case study, the clinicians in form of physiotherapist, general physicians as well nursing staff should have awareness about the prevailing level of competencies possessed by them so as to handle the case of Jim in best possible manner (Van der Hem-Stokroos and et. al., 2003). They must follow a good behavior and attitude which treating Jim for his prevailing condition. In the same way, knowledge is also required about patient Jim as well as physical issues being suffered so as to judge as well as treat his conditions in the best possible accords.

Knowing the Patient and Person – A fully fledged knowledge as well as information is required to be gained for patient. These are in terms of preferences preferred by Jim, his experience with pain, current physical fitness as well as care needs so as to provide for best possible solution to the persisting issues (Whitney, 2003). Clinical reasoning will only be effective if clinicians rerating Jim are knowledgeable about mobility as well as present level of functioning.

Knowing the Environment - There is further a requirement to have an awareness about varied approaches that are used for clinical reasoning (Harasym, Tsai and Hemmati, 2008).

In this regard, effective information is crucial for provision of professional nursing care so as to capture as well as share information about patients with respect to health care needs and other concerns (Kellett, Clarke and Matthews, 2005). Having a good source of information is crucial for empowering them as well as partners when they are in the process of decision making. For example, in present scenario, Jim has been suffering from shoulder pain. It is essential to find out the exact nature of pain. In this regard, the role of knowledge will be to empower the nursing staff as well as healthcare professionals towards deciding the form of treatment which is required to be given to Jim as per his prevailing condition (Kapur, 2009). Nurses, health visitors and midwives that are working on condition of Jim are required to record as well as generate a lot of information to maintain as well as improve the overall care. In this regard, information can only be obtained if continuous form of interaction occurs with the patients, families and other multidisciplinary team members (Japp and Robertson, 2013). The nurses in case of Jim are required to assess the overall holistic care needs so that plans can be developed and shared with others whenever found appropriate. It is only by reviewing information in a continuous manner there can be a generation of care outcomes.

Boshuizen, Schmidt and colleagues made a development of stage theory so as to emphasize towards developing knowledge of acquisition as well as expertise in clinical reasoning. The stage one will involve for acquiring the biomedical knowledge for explaining the cause and outcome of physical issues being faced by Jim for having an understanding about path physiological processes. This stage is basically referred to as knowledge encapsulation. In the section stage the acquired knowledge base is integrated into clinical practice in order to cause a simplified explanation of signs and symptoms. It is only by repeated application of knowledge there is a reorganization so as to achieve accessibility followed by efficient usage (DiCenso, Cullum and Ciliska, 2002). Hence, in this regard the reasoning process at this stage does not show sole reliance on biomedical concepts but knowledge can be retrieved when solving a complex problem such as that which is being faced by Jim.

Hence, as per second stage knowledge required for carrying out a thorough clinical reasoning can only be gained when actual contact is carried out with Jim. In stage three there is a presence of transition from the knowledge that has been organized in casual networks to a structure known as illness scripts (Harasym, Tsai and Hemmati, 2008). These are basically composed of many basic elements. They are inclusive of enabling disease related condition, fault as well as issues on account of fault. These scripts in case of Jim will assist towards generating experience faced by clinician with respect to certain diseases. In the last stage, the illness scripts of individual patients are stored on memory as instance scripts and are not merged for forming a disease prototype.

Role Of Clinical Reasoning In Enhancing And Safe Guarding Quality Of Care

Clinical reasoning is mainly used for referring to ways of thinking about care issues of the patient that includes determining, managing as well as preventing of problems of the client. Because of increased use of available evidence base, access to resources, socio cultural norms as well as ethical issues along with professional accountability, clinical reasoning has an increased role in enhancing the quality of care given to the patient for physiotherapy practice (Bleakley and, 2003). The process of clinical reasoning plays a significant role for the client given in the case named Jim as with this emphasis is laid on increased communication between patient and care worker (Paul and Elder, 2005). It is with implementation of clinical reasoning that clinicians attend to initial information either directly from the patient or from other family members. This help in formation of hypothesis as in case of Jim as exact deduction of his disease condition is still not known. With this, along with ongoing analysis of information about the patient further data is collected and interpreted which is a part of clinical reasoning.

Clinical reasoning plays a significant role in physiotherapy practice as it is the sum of thinking critically about the condition of patient and decision making processes that are associated with clinical practice (Gordon, 2006). Its importance lies in the fact that therapist analyses multiple variables that lead to limited physical activity of patient as in case of Jim who is having issues with movement in his hands while painting. The practice of clinical reasoning is helpful in enhancing the quality of care given to the service users as this involve connecting of present knowledge and past experiences in order to conduct proper decision making regarding treatment and management of the patient.

The process of clinical reasoning has focussed on medical diagnosis but this is only an initial point for a careful assessment of the patient and his conditions. It is possible that patients with same medical diagnosis may present with different mobility symptoms while on the other side, those with different medical diagnosis might have similar intervention needs (Whitney, 2003). Thus, clinical reasoning in physiotherapy has enhanced the quality of care as this has progressed from focussing on diagnosis of patient’s physical condition to broader categories (Japp and Robertson, 2013). Also, reasoning in collaboration with patients about these provide a more in depth understanding of problems of patient and thus help in identification of appropriate management strategies for the improvement of patient condition.

The process of clinical reasoning occurs through the interaction of physiotherapist and patient and others like carers and team members (Trede and Higgs, 2003). Here, treatment plans and management strategies are devised that are based on clinical data, knowledge as well as patient choice and professional judgement. This process of clinical reasoning enhances the quality of care as this involve choosing a particular treatment intervention over all possible options that are available and this continues throughout the entire management of patient (DiCenso, Cullum and Ciliska, 2002). Clinical reasoning further increases the extent of professional knowledge of the practitioner as this is gained through reading of textbooks and journals and this thus enhances the quality of care given to the patient (van der Hem-Stokroos and et. al., 2003). Thus, involvement of increasing of in depth knowledge and experience in relevant aspects of physiotherapy as in the present case of Jim with eventually results in increment of quality of care.

Clinical reasoning apart from increasing knowledge also involves the process of communicating of reasoning. Communication in reasoning involves professionals to articulate their reasoning to various parties involved in patient care. Clinical reasoning is communicated to oneself so as to assess for thinking and checking for reasoning errors as well as with peers so as to assess and justify for the decision for the intervention of patient (Bleakley and, 2003). Communication is also done with patient and care givers so as to educate them and take feedback from them and involve them in decision making. Thus, clinical reasoning help in enhancing of quality of care in physiotherapy practice for the patient Jim as with communication there can take place exchange of information, negotiating goals as well as treatment decisions for him (Arnold and Boggs, 2011).

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A critical, professional as well as scientific context of clinical reasoning is considered to be evidence based practice which involves integration of best available evidence into clinical reasoning process from research studies (Dawes, Summerskill, Glasziou and et al., 2005). In physiotherapy clinical reasoning along with best evidence practice improves quality of care as therapists integrate their clinical judgement and experience with unique needs and characteristics of the patient in order to make proper decision for the client (Harasym, Tsai and Hemmati, 2008). Evidence based practice in clinical reasoning offers a scientific and systematic approach to clinical practice as in case of Jim in providing proper physiotherapy care to him through the process of deductive and objective application of empirical knowledge to that of specific problem of Jim (DiCenso, Cullum and Ciliska, 2002).

Clinical reasoning plays a significant role in improving quality of care in physiotherapy practice as this also focus on patient and family centred care. Nowadays, patient care is not only limited to taking decisions by the practitioner on their own and impart treatment to them. But rather, patients also need to have accurate information about their medical condition and intervention for them. This also includes involvement of patients in decision making for them by physiotherapists and thus clinical reasoning focuses on patient centred care. With adopting such an approach, there is identification of collaboration of physiotherapists with patients as central to clinical reasoning (Simmons and et al., 2003). As there is now more of consumer focused service so critical reasoning lead eventually to improvement of quality of care for the patient.

Critical reasoning also involves moral and ethical reasoning which means that intervention provided to the patient is such that it meets all moral and ethical standards and does not go against the ethical guidelines. All treatment given to patient is such that it is with consent and permission of patient and its family members and nothing is done against their wish. In this respect, following of moral and ethical standards improves the quality of care given to the patient. Clinical reasoning also involves team work and collaboration as only one physiotherapist does not provide care to the client. This includes peers of the therapist, senior professionals and family members or care givers of the patient (Noll, Key and Jensen, 2001). Working with such a team in collaboration by establishing communication with them result in advanced clinical reasoning and thus quality of physiotherapy care for the patient Jim in the case.

Core Principles Which Underpin Advanced Clinical Reasoning And Its Application Acknowledging Limitations

As per the process of clinical reasoning that has been drawn from given case study of Jim as well as my own experience I have identified many core elements related to my clinical reasoning process and model. The process used by me for the purpose of clinical reasoning has been developed from the case study and you’re my experience to develop and present the model of clinical reasoning. While working with my patients I have understood the need of inculcating the concept of clinical reasoning in my everyday practice. It is clear that these days’ people have been found to suffer from complex as well as chronic set of problems (DiCenso, Cullum and Ciliska, 2002). Hence the health care professionals like me have been expected to become more responsible so as to work in diverse teams and make judgments as well as decisions on an independent level. Hence, I consider clinical reasoning as a complex skill which is used for understanding the significance of patient related data so as to diagnose the issues faced by them. This is followed by intake of clinical decisions to resolve the issues and achieve outcomes related to patients.

However, as per my experience as well as understanding regarding the concept of clinical reasoning, I have found a presence of many ethical and ethical issues that are most likely to put an impact on my overall reasoning. While working with my patients, I used to face an issue regarding a particular treatment option or a course of action that is required to be taken by me while treating the patients (Japp and Robertson, 2013). These may be correct legally but ethically wrong or vice versa. In this regard for the avoidance of such circumstances from occurring I have always focused on creation of open as well as honest communication. It can be considered as a pre requisite so as to make informed as well as responsible decisions (Harasym, Tsai and Hemmati, 2008). Other than this my clinical reasoning while working as a part of a diverse team has also been affected by many factors. Most of my overall power to make important decisions has been impacted by the organizational structure of the hospital of which I have been a part of. The policies as well as procedural setting followed by a hospital somewhere impacted my overall decision making. In the same way, I sometimes got an access to supportive resources which assisted towards making decision.

Other than this, there has also been a presence of varied patient centered influences that put an impact on the process of clinical reasoning. In this regard, I have found out while carrying out my works that some of the patients have shown an increased adherence to treatment which has assisted in the overall process of clinical reasoning. In other situations, they have been found to show an inappropriate behavior (Bleakley and, 2003). These have been in form of non attendance shown towards follow up program or not adhering to the wishes of doctor. In the same way, I have also seen many patients getting worried about the overall outcome of treatment. Hence, they sometimes bestowed a negative attitude towards treatment mechanism provided by doctor. It thus affected the overall process of clinical reasoning that was carried out for providing the best outcomes to patient.


From the above report it can be concluded that clinical reasoning is a very crucial component of nursing practice. The nudes as well as other healthcare professionals are required to make effective decisions in such a manner so as to provide for a quality care. In this regard, there is a presence of many different kind of models that put an impact on the overall process of clinical decision making so as to affect the provision of care. In the same way, while ensuring towards making any clinical decision, the requirement is to give a due consideration towards patient situation, collection as well as processing of information, identifying issues, establishes goals, taking action followed by evaluation of outcomes so as to reflect on process and new learning (Japp and Robertson, 2013). It has further been found out that clinicians has been bringing in a lot of wisdom, expertise, understanding followed by sensitivity to this process of reasoning. But, there is also a presence of many non-clinical influences that sometimes stimulate or may inhibit the process of clinical reasoning.

From the report, I have further arrived on a conclusion that my clinical reasoning has developed by undertaking the process of met cognitive thinking. I have further adopted a process of think aloud approach in any given situation. This was basically done by me during the process when I was made to undertake decision during a clinical encounter with patients. This helped me in developing my own reasoning strategies. I also learned the tact of clinical reasoning from other experienced clinicians. They followed the tact of reflecting properly on a broader as deeper scale issues so as to merge the past experiences and think followed by deciding of a broader level.


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  • Arnold, E. and Boggs, K., 2011. Interpersonal relationships: professional communication skills for nurses. St. Louis: Saunders.
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  • Bartlett, R., and, 2008. Evaluation of the outcome-present state test model as a way to teach clinical reasoning in undergraduate students in a psychiatric mental health nursing course. J Nurs Educ.
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