Interprofessional learning
through simulation
Importance of clinical reasoning: a case study
T
HIS CLINICAL TRAINING INITIATIVE IS SUPPORTED BY FUNDING FROM
THE AUSTRALIAN GOVERNMENT UNDER THE INCREASED CLINICAL
TRAINING CAPACITY (ICTC) PROGRAM
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Importance of Clinical Reasoning in Interprofessional Learning through Simulation, Lecture notes of Reasoning
The importance of interprofessional learning and clinical reasoning in healthcare. It highlights the role of simulation in providing a safe learning environment for students to practice and improve communication and collaboration among health professionals. The document also emphasizes the benefits of interprofessional education and collaborative practice in enhancing patient care and safety. ECU's IpAC Program is presented as an example of interprofessional learning initiatives supported by the Australian Government.
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Interprofessional learning
through simulation
Importance of clinical reasoning: a case study
THIS CLINICAL TRAINING INITIATIVE IS SUPPORTED BY FUNDING FROM
THE AUSTRALIAN GOVERNMENT UNDER THE I NCREASED CLINICAL
TRAINING C APACITY (ICTC) PROGRAM
THIS CLINICAL TRAINING INITIATIVE IS SUPPORTED BY FUNDING FROM THE AUSTRALIAN
- Acknowledgements Table of Contents
- Foreword
- Interprofessional Ambulatory Care Program
- ECU Health Simulation Centre
- Interprofessional learning
- Interprofessional learning through simulation
- How to use this resource package
- Scenario brief
- Key learning competencies
- Interprofessional communication
- Client centred care
- Reflective practice
- Key discussion points
- Segment 1: Physiotherapy.................................................................................................
- Segment 2: Medical Emergency Team (MET)
- Segment 3: Resolution
- Segment 4: Debrief..........................................................................................................
- Literature review
- Clinical reasoning in clinical practice
- Teaching clinical reasoning
- Clinical reasoning process
- The Clinical Reasoning Cycle
- The Clinical Reasoning Cycle for Russell Stanton........................................................
- Decision-making framework
- Conclusion
- Medical glossary and acronyms
- Further information
- References
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specialist centre in providing human factors based sequential simulation programs using professional actors. Most simulated learning interactions revolve around a single moment, such as a patient’s admission to the emergency department. What we provide at the ECU Health Simulation Centre is a sequential simulated learning event that follows the patient and carer’s journey through the healthcare system, for example, from the accident site following a motor vehicle accident, to the emergency department, to a hospital ward, to their home and into the community for GP and allied health follow-up.
Human factors in health care are the non-technical factors that impact on patient care, including communication, teamwork and leadership. Awareness of and attention to the negative aspects of clinical human factors improves patient care.
ECU’s involvement in national health workforce reform is all about playing a role that enables the health workforce to better respond to the evolving care needs of the Australian community in accordance with the NPA’s agenda. The IpAC Program is an example of how we can work across sectors, nationally and internationally, to determine better ways of addressing the pressing issue of how best to prepare students for the workplace and thus assuring that health systems have safe, high quality health services.
Interprofessional Ambulatory Care Program
ECU’s IpAC Program was established with support from the Australian Federal Government through funding from the ICTC Program. The IpAC Program aims to deliver a world-class interprofessional learning environment and community clinic that develops collaborative practice among health professionals and optimises chronic disease self-management for clients.
This is achieved through the provision of clinical placements within the multidisciplinary team at the IpAC Unit, a community clinic that develops communication and collaboration among health professionals and optimises chronic disease self-management for clients. Additionally, a range of clinical placements are offered at existing health facilities, where trained IpAC Program clinical supervisors provide clinical support and ensure the integration of interprofessional learning into each clinical placement.
THIS CLINICAL TRAINING INITIATIVE IS SUPPORTED BY FUNDING FROM THE AUSTRALIAN
The IpAC Unit, in collaboration with the ECU Health Simulation Centre, has developed a range of interprofessional learning through simulation resources. These learning resources are packages consisting of an audiovisual resource and a facilitator’s manual, and aim to facilitate interprofessional learning and to support the participants in the development of interprofessional skills.
The interprofessional learning through simulation resources developed by the IpAC Program aim to provide health students and health professionals with the opportunity to learn with, from and about one another by engaging them in interactive live simulation events. These simulations encourage students and professionals to challenge themselves and each other in a safe learning environment.
ECU Health Simulation Centre
ECU houses the only fully functioning Health Simulation Centre of its kind in Western Australia, specifically designed and equipped to address the interprofessional learning needs of the health workforce and implementation of both state and national safety and quality frameworks.
The ECU Health Simulation Centre offers health workforce training and development specialising in clinical skills, human factors, and patient safety training for multidisciplinary health teams. Using a variety of educational techniques, including a broad range of simulation mannequins, professional actors and task trainers, ECU specialises in immersive simulation and observational learning. Supporting the ECU Health Simulation Centre are nursing, medical, paramedic and psychology academic and technical staff whose aim is to cultivate the development of competent and confident health professionals centred on enhancing patient safety.
Interprofessional learning
Interprofessional education occurs when two or more professions learn with, from and about each other in order to improve collaboration and quality of care (Centre for the Advancement of Interprofessional Education, 2002).
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Interprofessional learning through simulation combines the principles of interprofessional learning and the use of simulation as an educational methodology. Interprofessional learning through simulation provides students with the opportunity to practice working with other health professionals and allows participants to explore collaborative ways of improving communication aspects of clinical care (Kenaszchuk, et al., 2011).
Many of the interdisciplinary team core competencies, such as problem solving, respect, communication, shared knowledge and skills, patient-centred practice, and the ability to work collaboratively (Canadian Interprofessional Health Collaborative, 2010) can all be developed by interprofessional learning through simulation.
Teamwork and interprofessional practice and learning are being recognised as central to improving client care and outcomes and enhancing client safety (Sargent, 2008). Promoting patient safety through team efforts is one of the five core competencies identified by the Institute of Medicine ( 2003 ).
In today’s healthcare setting, no one health professional can meet all of the client’s needs and therefore a healthcare team approach is required. Interprofessional learning through simulation provides learning opportunities to prepare future healthcare professionals for the collaborative models of healthcare being developed internationally (Baker et al., 2008).
How to use this resource package
This interprofessional learning through simulation resource package has been designed to support the facilitation of interprofessional learning among students and practitioners with an interest in developing their skills and knowledge of interprofessional practice.
The package consists of two components: an audiovisual resource and a supporting manual. In order to optimise the learning opportunities from this package it is recommended that participants are firstly introduced to the concepts of interprofessional learning and human factors in health care.
The package has been created in a format to enable flexibility in its application depending on the educational setting. We recommend the following format:
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- Facilitator guided discussion around the concepts of interprofessional learning and human factors in health care.
- View audiovisual resource in its entirety.
- View segments of the audiovisual resource.
- The viewing of each segment is followed by a facilitator guided discussion around the scenario specific learning competency areas (samples for each discussion are given within the manual).
- After the last segment: facilitator guided discussion, identifying and discussing the changes witnessed and how this impacted on the alternative outcome. In particular discussion relating these changes to personal (future) practice is essential in improving interprofessional practice.
Opportunities for further reading and exploration of the scenario are provided in the Further Information and References sections of this resource manual.
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- The development of trusting relationships with clients/families and other team members.
Client centred care
The interaction between team members and the client demonstrates:
- The sharing of information with clients in a respectful manner.
- Communicating with clients in a way that is clear, understandable and free of jargon.
- Listening respectfully to the needs of all parties to ensure the most appropriate care.
- The interaction is supportive to the client.
Reflective practice
Reflective practice is crucial in continuous development and re-assessment of skills when working in health care. A reflective practitioner:
- Reflects on feedback and integrates changes into practice.
- Reflects on how perceptions, attitudes and beliefs impact on practice.
- Identifies knowledge deficits and seeks clarification.
Key discussion points
Segment 1: Physiotherapy
What is happening to the patient? Why is the physiotherapist concerned? A. This may be autonomic dysreflexia, a medical emergency, as it may result in seizures and even death. Is the blood pressure (BP) a concern? A. This patient has a BP of 140/90. In the average population a BP of below 130/80 is optimum, anything over 140/90 can be considered abnormal. The normal BP for a person with a quadriplegic injury falls within the range of 80/40 to 100/60, and a BP of 140/90 is very high (Claydon & Krassioukov, 2006). What is a MET call and who can call it? Why is the physiotherapist placing a MET call? A. MET is a Medical Emergency Team, comprised of staff who possess expertise in the management of an acutely unwell patient. The MET aims to prevent serious adverse events in hospital, but also enables education and sharing of critical care skills with ward staff and the ability to advise on patient management and follow up (Jevon, 2010).
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A. Autonomic Dysreflexia is a medical emergency because of the possible impact on the patient’s health. How is the patient feeling? What can the health professionals do to reduce his fear? A. The physiotherapist is talking very calmly and knows what to do in this situation so this will have a calming effect on the patient. A. The student is letting the more experienced physiotherapist take the lead. A. Telling the patient what the possible problem is may or may not alleviate his stress.
What did the physiotherapist and the student do well, and what could they have done better? Did the physiotherapist use the clinical reasoning cycle? (see page 15 of this manual)
Segment 2: Medical Emergency Team (MET)
How would you describe the communication within the team? If you were the student nurse, how would you feel when called out on the MET call? Is this student supported by the other members of the team? Is she an active team member? A. The Registered Nurse checks the knowledge of the student nurse which could be seen as supportive or undermining. Who is the team leader? Why is this person the team leader? A. This question could generate a discussion about the role of the Registered Nurse and the Doctor as both show leadership characteristics. How do the team members ensure each team member has the same information? Who summarises the patient file? Do they have all the relevant information? A. The Doctor summarises the information and checks this with the other team members to ensure everyone has the same information. Does the team use the clinical reasoning cycle? (see page 15 of this manual)
Segment 3: Resolution
Give examples of how the team is working well together and how they could improve their work together. A. Discuss each team member: Doctor, Nurse, Nursing student, Physiotherapist, Physiotherapy student. Is the patient part of the team? A. The team members ask each other questions about his bowel movement and other physical tests but they do not ask the patient himself.
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How do you think the patient felt in each segment of this scenario? Could you describe what caused the patient to feel like this? A. Even though the patient had been informed about Autonomic Dysreflexia experiencing the sudden rise in blood pressure with the knowledge this may be life threatening was a stressful situation for the patient. A. The patient will feel more informed after this event and will more easily recognise the symptoms so that he can advise his carers about this medical emergency. Do the health professionals and students feel more or less confident after this event? Why?
What has this scenario highlighted for your personal (future) practice? What aspects of interprofessional learning objectives were highlighted most strongly for you:
- Interprofessional communication;
- Client centred care; or
- Reflective practice. What changes will you make in your personal (future) practice to in improve interprofessional practice?
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Literature review
Ebright et al (2003, p. 631) states that health care professionals ‘ need to manage complexity in the midst of a changing environment’. The failure to ensure adequate thought and clinical reasoning can have a negative impact on a patient’s condition (Aitken, 2003). According to Levett-Jones et al (2010, p. 515) clinical reasoning is the method in which health care professionals ‘collect cues, process the information, come to an understanding of a patients’ problem or situation, plan and implement interventions, evaluate outcomes and reflect on and learn from the process’. In basic terms, clinical reasoning is a term which describes the process used by health professionals to make informed decisions about and solve problems arising in patient care.
Clinical reasoning in clinical practice
Health care professionals need to be flexible in their approach to decision-making and ensure continuity of care. The health care professional’s ability to provide safe, high quality health care can be dependent on their ability to reason, think and judge, which can be limited by lack of experience (Benner, Hughes, & Sutphen, 2008). Simmons (2010, p. 1155) states that ‘ clinical reasoning is a complex cognitive process that uses formal and informal thinking strategies to gather and analyse patient information’. This process is reliant on the health care professional using both their intuition and knowledge to influence decision-making for individual client circumstances. The experience and knowledge of the health care professional is an important consideration in the consolidation of clinical reasoning.
Simmons ( 2010 ) considers this by suggesting that newly qualified nurses, for example, may identify fewer cues, have difficulty identifying complex diagnosis and may not re-evaluate data as often as experienced nurses. This has the potential to have a negative impact on patient care. Hamm (1991, cited in Round, 2001) agrees that the clinical situation and the practitioner’s knowledge and clinical experience could impact on the clinical reasoning employed and its efficiency. However, an individual’s extensive experience could be irrelevant if faced with a situation that they have not previously been exposed to. Thompson and McCaughan ( 2002 ) conclude that a good clinical decision is one that takes into account the current best practices, considers patient preferences and is undertaken by experienced health professionals.
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The Clinical Reasoning Cycle
The Clinical Reasoning Cycle requires health care professional to examine and discuss the steps in a clockwise direction to facilitate decision-making, enabling the clear formulation of a care plan (Levett-Jones, et al., 2010). This cycle has been applied in the current scenario involving patient Russell Stanton. The thought processes of the care team who was caring for Russell will be explored through application of the Clinical Reasoning Cycle to demonstrate how this decision-making process is used in practice.
Source: (University of Newcastle, 2009)
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The Clinical Reasoning Cycle for Russell Stanton
Step 1: Consider the patient situation Russell Stanton is a 25-year-old male who is being treated for C6 Tetraplegia as a result of a rugby accident six weeks prior.
Step 2: Collect cues and information Review the client’s current medical history and gather specific information on the present activity/treatment. Russell was undergoing passive arm mobilisation treatment with a Physiotherapy student when he suddenly felt unwell_._
Step 3: Process information Recognise the changes in the patient’s condition. In doing so, try and distinguish between the changes that need immediate intervention and changes that should be considered for future care. Look to see whether there are any relationships between the changes, particularly relating it to past experiences. Predict a possible expected outcome. There is a sudden change or deterioration in Russell’s condition. He is complaining of:
- Headache
- Blocked nose
- ‘Sweating’ and feeling flushed
The Physiotherapist suggests it could be Autonomic Dysreflexia.
Step 4: Identify problems and issues Examine the facts to establish a definitive diagnosis. The Physiotherapist is aware of the potential severity of this situation and asks the Physiotherapy student to sit Russell up to 90 degrees and take his blood pressure, which would be elevated if Russell has Autonomic Dysreflexia as suspected. The blood pressure is hypertensive at 140/90.
The Physiotherapist puts out a call to the Medical Emergency Team (MET).
Step 5: Establish the goal/s Make a plan of care with specific outcomes which relate to a realistic time frame.
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Step 8: Reflection Consider the treatment given and establish what you have learnt, what went well and what could be improved.
- The student Physiotherapist should have paid more attention to Russell’s concerns and called for assistance sooner, as he himself was unsure of the cause of Russell’s deterioration.
- The student Physiotherapist has learnt a valuable lesson in specific complications that can occur in spinal injury patients.
- The Physiotherapist acted promptly by recognising the early signs of Autonomic Dysreflexia.
- The MET were quick to establish the cause of the problem before Russell’s condition became too compromised.
- The Physiotherapist allocated time to provide the Physiotherapy student with the opportunity to debrief on the client’s sudden deterioration and highlight any further training needs.
The clinical reasoning cycle has facilitated a positive outcome for Russell. The health care professionals had a logical and succinct process to follow. They reflected on the predisposing facts of the situation to assist in the examination of the patient and consideration of the relevant information in a timely manner. The clinical reasoning process of examination can be transcribed into Russell’s medical notes in the process followed which ensures all details are accounted for, fulfilling the duty of care.
Decision-making framework
In 2006 a review conducted by the Australian Nursing and Midwifery Council (ANMC) concluded that the introduction of a decision-making framework encouraged health professionals to become more accountable for their clinical decisions and provided novice nurses with an opportunity to develop their clinical knowledge and re-evaluate data as effectively as experienced nurses (Australian Nursing & Midwifery Council, 2006). Within this review the Nursing Board of Western Australia (NBWA) advocated utilising a specific framework for decision-making as this encouraged nurses’ to ‘think about what they were doing’ and therefore improves their critical thinking. The review also found that nurses who utilised a decision-making framework became more empowered to turn down clinical practices they didn’t feel competent in undertaking. They concluded that this leads to a
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consistency of clinical practice standards and enhanced interprofessional communication as all staff followed the same decision-making process (Australian Nursing & Midwifery Council, 2006 ).
Conclusion
Clinical reasoning is an informed decision-making process that is being increasingly recognised as important for health care professionals working within a complex health care environment and caring for the increasingly multifaceted care needs of their patients. The ability to problem solve has been found to become more sophisticated with increasing clinical experience. However, the use of formal decision-making tools such as the ‘Clinical Reasoning Cycle’ outlined in detail above, facilitates sequential problem solving that allows health care professionals of all abilities and levels of experience to better assess, develop and implement the best care for their patients.